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Griesel R, Banda CG, Zhao Y, Omar Z, Wiesner L, Meintjes G, Sinxadi P, Maartens G. Pharmacokinetics of Single-Dose Versus Double-Dose Dolutegravir After Switching From a Failing Efavirenz-Based Regimen. J Acquir Immune Defic Syndr 2024; 96:85-91. [PMID: 38372621 DOI: 10.1097/qai.0000000000003402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/09/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Dolutegravir exposure is reduced after switching from efavirenz, which could select for dolutegravir resistance if switching occurs during virologic failure. METHODS We measured serial dolutegravir trough concentrations after switching from efavirenz in a clinical trial, which randomized some participants to a supplemental dolutegravir dose or placebo for the first 14 days. Changes in dolutegravir trough concentrations between days 3, 7, 14, and 28 were evaluated. The primary outcome was the geometric mean ratio of dolutegravir trough concentrations on day 7 versus day 28. RESULTS Twenty-four participants received double-dose dolutegravir (50 mg twice daily) and 11 standard dose for the first 14 days. Baseline characteristics were 77% female, median age 36 years, CD4 cell count 254 cells/mm3, and HIV-1 RNA 4.0 log10 copies/mL. The geometric mean ratio (90% CI) of dolutegravir trough concentrations on day 7 versus day 28 was 0.637 (0.485 to 0.837) in the standard-dose group and 1.654 (1.404 to 1.948) in the double-dose group. There was a prolonged induction effect at day 28 in participants with efavirenz slow metaboliser genotypes. One participant in the double-dose group had a dolutegravir trough concentration below the protein-binding adjusted concentration needed to inhibit 90% of HIV-1 (PA-IC90) at day 3. CONCLUSIONS No participants on standard-dose dolutegravir had dolutegravir trough concentrations below the PA-IC90. Slow efavirenz metaboliser genotypes had higher baseline efavirenz concentrations and more pronounced and longer period of induction postswitch. These findings suggest that a 14-day lead-in supplemental dolutegravir dose may not be necessary when switching from a failing efavirenz-based first-line regimen.
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Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Clifford G Banda
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ying Zhao
- Department of Medicine, University of Cape Town, Cape Town, South Africa ; and
| | - Zaayid Omar
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa ; and
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Platform for Pharmacogenomics Research and Translation (PREMED), University of Cape Town, South African Medical Research Council, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Abdelgawad N, Wasserman S, Abdelwahab MT, Davis A, Stek C, Wiesner L, Black J, Meintjes G, Wilkinson RJ, Denti P. Linezolid Population Pharmacokinetic Model in Plasma and Cerebrospinal Fluid Among Patients With Tuberculosis Meningitis. J Infect Dis 2024; 229:1200-1208. [PMID: 37740554 PMCID: PMC11011161 DOI: 10.1093/infdis/jiad413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 09/09/2023] [Accepted: 09/20/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Linezolid is evaluated in novel treatment regimens for tuberculous meningitis (TBM). Linezolid pharmacokinetics have not been characterized in this population, particularly in cerebrospinal fluid (CSF), as well as, following its co-administration with high-dose rifampicin. We aimed to characterize linezolid plasma and CSF pharmacokinetics in adults with TBM. METHODS In the LASER-TBM pharmacokinetic substudy, the intervention groups received high-dose rifampicin (35 mg/kg) plus 1200 mg/day of linezolid for 28 days, which was then reduced to 600 mg/day. Plasma sampling was done on day 3 (intensive) and day 28 (sparse). A lumbar CSF sample was obtained on both visits. RESULTS Thirty participants contributed 247 plasma and 28 CSF observations. Their median age and weight were 40 years (range, 27-56) and 58 kg (range, 30-96). Plasma pharmacokinetics was described by a 1-compartment model with first-order absorption and saturable elimination. Maximal clearance was 7.25 L/h, and the Michaelis-Menten constant was 27.2 mg/L. Rifampicin cotreatment duration did not affect linezolid pharmacokinetics. CSF-plasma partitioning correlated with CSF total protein up to 1.2 g/L, where the partition coefficient reached a maximal value of 37%. The plasma-CSF equilibration half-life was ∼3.5 hours. CONCLUSIONS Linezolid was readily detected in CSF despite high-dose rifampicin coadministration. These findings support continued clinical evaluation of linezolid plus high-dose rifampicin for the treatment of TBM in adults. Clinical Trials Registration. ClinicalTrials.gov (NCT03927313).
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Affiliation(s)
- Noha Abdelgawad
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Sean Wasserman
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Institute for Infection and Immunity, St George's University of London, United Kingdom
| | - Mahmoud Tareq Abdelwahab
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Angharad Davis
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
- Faculty of Life Sciences, University College London, United Kingdom
| | - Cari Stek
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - John Black
- Department of Medicine, Walter Sisulu University, Mthatha, South Africa
| | - Graeme Meintjes
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Department of Medicine, University of Cape Town, South Africa
| | - Robert J Wilkinson
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
- Department of Infectious Diseases, Imperial College London, United Kingdom
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
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Gausi K, Ignatius EH, De Jager V, Upton C, Kim S, McKhann A, Moran L, Wiesner L, von Groote-Bidlingmaier F, Marzinek P, Vanker N, Yvetot J, Pierre S, Rosenkranz SL, Swindells S, Diacon AH, Nuermberger EL, Denti P, Dooley KE. High-Dose Isoniazid Lacks EARLY Bactericidal Activity Against Isoniazid-resistant Tuberculosis Mediated by katG Mutations: A Randomized, Phase 2 Clinical Trial. Am J Respir Crit Care Med 2024. [PMID: 38564365 DOI: 10.1164/rccm.202311-2004oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
RATIONALE Observational studies suggest that high-dose isoniazid may be efficacious in treating multidrug-resistant tuberculosis (MDR-TB). However, its activity against Mycobacterium tuberculosis (M.tb) with katG mutations (which typically confer high-level resistance) is not established. OBJECTIVE To characterize early bactericidal activity (EBA) of high-dose isoniazid in patients with tuberculosis caused by katG-mutated M.tb. METHODS A5312 was a Phase 2A randomized, open-label trial. Participants with tuberculosis caused by katG-mutated M.tb were randomized to receive 15 or 20 mg/kg isoniazid daily for 7 days. Daily sputum samples were collected for quantitative culture. Intensive PK sampling was performed on day 6. Data were pooled across all A5312 participants for analysis (drug-sensitive, inhA-mutated, and katG-mutated M.tb). EBA was determined using nonlinear mixed-effects modelling. RESULTS Of 80 treated participants, 21 had katG-mutated M.tb. Isoniazid PK was best described by a two-compartment model with an effect of NAT2 acetylator phenotype on clearance. Model-derived Cmax and AUC in the 15 and 20 mg/kg groups were 15.0 and 22.1 mg/L and 57.6 and 76.8 mg∙h/L, respectively. Isoniazid bacterial kill was described using an effect compartment and a sigmoidal Emax relationship. Isoniazid potency against katG-mutated M.tb was approximately 10-fold lower than against inhA-mutated M.tb. The highest dose (20 mg/kg) did not demonstrate measurable EBA, except in a subset of slow NAT2 acetylators (who experienced the highest concentrations). There were no grade 3 or higher drug-related adverse events. CONCLUSIONS This study found negligible bactericidal activity of high-dose isoniazid (15-20 mg/kg) in the majority of participants with tuberculosis caused by katG-mutated M.tb. Clinical trial registration available at www. CLINICALTRIALS gov, ID: NCT01936831.
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Affiliation(s)
- Kamunkhwala Gausi
- University of Cape Town, 37716, Department of Medicine, Observatory, Western Cape, South Africa
- South Africa
| | | | - Veronique De Jager
- TASK Applied Science, TASK Clinical Research Centre, Cape Town, South Africa
| | | | - Soyeon Kim
- Frontier Science Foundation, 2402, Brookline, Massachusetts, United States
| | - Ashley McKhann
- Harvard T.H. Chan School of Public Health, Boston, United States
| | - Laura Moran
- Social & Scientific Systems Inc, 43740, Silver Spring, Maryland, United States
| | - Lubbe Wiesner
- University of Cape Town Faculty of Health Sciences, 63726, Observatory, Western Cape, South Africa
| | | | - Philip Marzinek
- Frontier Science Foundation, 2402, Amherst, New York, United States
| | | | - Joseph Yvetot
- GHESKIO Centers, Port-au-Prince, Haïti;, Port-au-Prince, Haiti
| | | | - Susan L Rosenkranz
- Harvard University T H Chan School of Public Health, 1857, Boston, Massachusetts, United States
- Frontier Science and Technology Research Foundation, 2402, Boston, Massachusetts, United States
| | | | | | | | - Paolo Denti
- University of Cape Town Faculty of Health Sciences, 63726, Observatory, Western Cape, South Africa;
| | - Kelly E Dooley
- Vanderbilt University Medical Center, 12328, Medicine, Nashville, Tennessee, United States
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Bekker A, Yang J, Wang J, Cotton MF, Cababasay M, Wiesner L, Moye J, Browning R, Nakwa FL, Rabie H, Violari A, Mirochnick M, Cressey TR, Capparelli EV. Safety and Pharmacokinetics of Lopinavir/Ritonavir Oral Solution in Preterm and Term Infants Starting Before 3 Months of Age. Pediatr Infect Dis J 2024; 43:355-360. [PMID: 38190642 PMCID: PMC10939833 DOI: 10.1097/inf.0000000000004243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Study of liquid lopinavir/ritonavir (LPV/r) in young infants has been limited by concerns for its safety in neonates. METHODS International Maternal Pediatric Adolescent AIDS Clinical Trials Network P1106 was a phase IV, prospective, trial evaluating the safety and pharmacokinetics of antiretroviral medications administered according to local guidelines to South African preterm and term infants <3 months of age. Safety evaluation through 24-week follow-up included clinical, cardiac and laboratory assessments. Pharmacokinetic data from P1106 were combined with data from International Maternal Pediatric Adolescent AIDS Clinical Trials Network studies P1030 and P1083 in a population pharmacokinetics model used to simulate LPV exposures with a weight-band dosing regimen in infants through age 6 months. RESULTS Safety and pharmacokinetics results were similar in 13/28 (46%) infants initiating LPV/r <42 weeks postmenstrual age (PMA) and in those starting ≥42 weeks PMA. LPV/r was started at a median (range) age of 47 (13-121) days. No grade 3 or higher adverse events were considered treatment related. Modeling and simulation predicted that for infants with gestational age ≥27 weeks who receive the weight-band dosing regimen, 82.6% will achieve LPV trough concentration above the target trough concentration of 1.0 µg/mL and 56.6% would exceed the observed adult lower limit of LPV exposure of 55.9 µg·h/mL through age 6 months. CONCLUSIONS LPV/r oral solution was safely initiated in a relatively small sample size of infants ≥34 weeks PMA and >2 weeks of life. No serious drug-related safety signal was observed; however, adrenal function assessments were not performed. Weight-band dosing regimen in infants with gestational age ≥27 weeks is predicted to result in LPV exposures equivalent to those observed in other pediatric studies.
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Affiliation(s)
- Adrie Bekker
- Family Centre for Research with Ubuntu, Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Jincheng Yang
- Department of Pediatrics and Skaggs School of Pharmacy and Pharmaceutical Science, University of California, San Diego, USA
- Clinical Pharmacology and Quantitative pharmacology, CPSS, AstraZeneca R&D, Waltham, MA, USA
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mark F. Cotton
- Family Centre for Research with Ubuntu, Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Mae Cababasay
- Clinical Pharmacology and Quantitative pharmacology, CPSS, AstraZeneca R&D, Waltham, MA, USA
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Jack Moye
- Division of Extramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Renee Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases
| | - Firdose L. Nakwa
- Department of Pediatrics and Child Health, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Helena Rabie
- Family Centre for Research with Ubuntu, Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Avy Violari
- Perinatal HIV research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Mirochnick
- Division of Neonatology, Department of Pediatrics, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Tim. R Cressey
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Molecular & Clinical Pharmacology, University of Liverpool, UK
| | - Edmund V. Capparelli
- Department of Pediatrics and Skaggs School of Pharmacy and Pharmaceutical Science, University of California, San Diego, USA
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Maputla SP, Van Dalen W, Joubert A, Norman J, Castel S, van der Merwe M, Wiesner L. A validated liquid chromatography-tandem mass spectrometry assay for the analysis of isoniazid and its metabolite acetyl-isoniazid in urine. J Mass Spectrom Adv Clin Lab 2024; 32:11-17. [PMID: 38356778 PMCID: PMC10865391 DOI: 10.1016/j.jmsacl.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/29/2024] [Accepted: 02/01/2024] [Indexed: 02/16/2024] Open
Abstract
Introduction Isoniazid (INH) is one of the most effective and potent first-line anti-tubercular drug. INH is also effectively administered as a preventative monotherapy and has been shown to significantly reduce TB incidence. INH is primarily metabolised to acetyl-isoniazid (AcINH) in the liver. AcINH is mainly excreted in urine presenting as a target for monitoring adherence to INH therapy. Objective The study aimed to develop and fully validate a bioanalytical method using liquid chromatography-tandem mass spectrometry for the quantification of INH and AcINH in human urine. Methods The samples were prepared using solid phase extraction, with the internal standards isoniazid-d4 and acetyl-isoniazid-d4 being used. The extracts were chromatographed on an Atlantis T3 analytical column with an isocratic mobile phase. For detection, a AB Sciex™ API 5500 triple quadrupole mass spectrometer was used at unit resolution in the multiple reaction monitoring mode, following positive electrospray ionization. Results The analytical method demonstrated sufficient sensitivity, as indicated by average signal-to-noise ratios of 7.07 and 6.23 at the lower limit of quantification for INH and AcINH, respectively. Validation was performed over three consecutive batches, demonstrating accuracy, precision, and overall robustness based on peak area ratios within the analytical range of 0.234-30.0 µg/mL for both INH and AcINH. All required validation experiments were assessed and met the acceptance criteria guidelines of the US Food and Drug Administration and European Medicines Agency. The validated method was utilized to measure concentrations of AcINH in urine as a means of assessing adherence to the intake of isoniazid in order to prevent TB infection during a phase III open-label multicenter trial. Conclusion A bioanalytical method was developed and fully validated for quantifying isoniazid (INH) and acetyl-isoniazid (AcINH) in 100 µL of human urine.
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Affiliation(s)
- Sydwell Poulo Maputla
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Willem Van Dalen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Norman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marthinus van der Merwe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Nyambo K, Tapfuma KI, Adu-Amankwaah F, Julius L, Baatjies L, Niang IS, Smith L, Govender KK, Ngxande M, Watson DJ, Wiesner L, Mavumengwana V. Molecular docking, molecular dynamics simulations and binding free energy studies of interactions between Mycobacterium tuberculosis Pks13, PknG and bioactive constituents of extremophilic bacteria. Sci Rep 2024; 14:6794. [PMID: 38514663 PMCID: PMC10957976 DOI: 10.1038/s41598-024-57124-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 03/14/2024] [Indexed: 03/23/2024] Open
Abstract
Mycobacterial pathogens present a significant challenge to disease control efforts globally due to their inherent resistance to multiple antibiotics. The rise of drug-resistant strains of Mycobacterium tuberculosis has prompted an urgent need for innovative therapeutic solutions. One promising way to discover new tuberculosis drugs is by utilizing natural products from the vast biochemical space. Multidisciplinary methods can used to harness the bioactivity of these natural products. This study aimed to evaluate the antimycobacterial efficacy of functional crude extracts from bacteria isolated from gold mine tailings in South Africa. Bacterial strains were identified using 16S rRNA sequencing. The crude extracts obtained from the bacteria were tested against Mycobacterium tuberculosis H37Rv, Mycobacterium smegmatis mc2155, and Mycobacterium aurum A+. Untargeted HPLC-qTOF and molecular networking were used to identify the functional constituents present in extracts that exhibited inhibitory activity. A virtual screening workflow (VSW) was used to filter compounds that were strong binders to Mycobacterium tuberculosis Pks13 and PknG. The ligands returned from the VSW were subjected to optimization using density functional theory (DFT) at M06-2X/6-311++ (d,p) level of theory and basis set implemented in Gaussian16 Rev.C01. The optimized ligands were re-docked against Mycobacterium tuberculosis Pks13 and PknG. Molecular dynamics simulation and molecular mechanics generalized born surface area were used to evaluate the stability of the protein-ligand complexes formed by the identified hits. The hit that showed promising binding characteristics was virtually modified through multiple synthetic routes using reaction-driven enumeration. Three bacterial isolates showed significant activity against the two strains of Mycobacterium, while only two, Bacillus subtilis and Bacillus licheniformis, exhibited activity against both Mycobacterium tuberculosis H37Rv, Mycobacterium smegmatis mc2155, and Mycobacterium aurum A+. The tentatively identified compounds from the bacterial crude extracts belonged to various classes of natural compounds associated with antimicrobial activity. Two compounds, cyclo-(L-Pro-4-OH-L-Leu) and vazabitide A, showed strong binding against PknG and Pks13, with pre-MD MM-GBSA values of - 42.8 kcal/mol and - 47.6 kcal/mol, respectively. The DFT-optimized compounds exhibited the same docking scores as the ligands optimized using the OPSL-4 force field. After modifying vazabitide A, its affinity to the Pks13 binding site increased to - 85.8 kcal/mol, as revealed by the post-MD MM-GBSA analysis. This study highlights the potential of bacteria isolates from gold mine tailings as a source of new scaffolds for designing and optimizing anti-Mycobacterium agents. These agents synthesized in-silico can be further tested in-vitro to evaluate their efficacy.
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Affiliation(s)
- Kudakwashe Nyambo
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, 7505, Cape Town, South Africa
| | - Kudzanai Ian Tapfuma
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, 7505, Cape Town, South Africa
| | - Francis Adu-Amankwaah
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, 7505, Cape Town, South Africa
| | - Lauren Julius
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, 7505, Cape Town, South Africa
| | - Lucinda Baatjies
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, 7505, Cape Town, South Africa
| | - Idah Sithole Niang
- Department of Biotechnology and Biochemistry, University of Zimbabwe, B064, Mount Pleasant, Harare, Zimbabwe
| | - Liezel Smith
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, 7505, Cape Town, South Africa
| | - Krishna Kuben Govender
- Department of Chemical Sciences, University of Johannesburg, Doornfontein Campus, P.O. Box 17011, Johannesburg, 2028, South Africa
- National Institute for Theoretical and Computational Sciences (NITheCS), Cape Town, South Africa
| | - Mkhuseli Ngxande
- Computer Science Division, Department of Mathematical Sciences, Faculty of Science, University of Stellenbosch, Matieland, South Africa
| | - Daniel J Watson
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Vuyo Mavumengwana
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research; South African Medical Research Council Centre for Tuberculosis Research; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, 7505, Cape Town, South Africa.
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7
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Abdelgawad N, Chirehwa M, Schutz C, Barr D, Ward A, Janssen S, Burton R, Wilkinson RJ, Shey M, Wiesner L, McIlleron H, Maartens G, Meintjes G, Denti P. Pharmacokinetics of antitubercular drugs in patients hospitalized with HIV-associated tuberculosis: a population modeling analysis. Wellcome Open Res 2024; 7:72. [PMID: 37008250 PMCID: PMC10050909 DOI: 10.12688/wellcomeopenres.17660.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 03/05/2024] Open
Abstract
Background Early mortality among hospitalized HIV-associated tuberculosis (TB/HIV) patients is high despite treatment. The pharmacokinetics of rifampicin, isoniazid, and pyrazinamide were investigated in hospitalized TB/HIV patients and a cohort of outpatients with TB (with or without HIV) to determine whether drug exposures differed between groups. Methods Standard first-line TB treatment was given daily as per national guidelines, which consisted of oral 4-drug fixed-dose combination tablets containing 150 mg rifampicin, 75 mg isoniazid, 400 mg pyrazinamide, and 275 mg ethambutol. Plasma samples were drawn on the 3rd day of treatment over eight hours post-dose. Rifampicin, isoniazid, and pyrazinamide in plasma were quantified and NONMEM ® was used to analyze the data. Results Data from 60 hospitalized patients (11 of whom died within 12 weeks of starting treatment) and 48 outpatients were available. Median (range) weight and age were 56 (35 - 88) kg, and 37 (19 - 77) years, respectively. Bioavailability and clearance of the three drugs were similar between TB/HIV hospitalized and TB outpatients. However, rifampicin's absorption was slower in hospitalized patients than in outpatients; mean absorption time was 49.9% and 154% more in hospitalized survivors and hospitalized deaths, respectively, than in outpatients. Higher levels of conjugated bilirubin correlated with lower rifampicin clearance. Isoniazid's clearance estimates were 25.5 L/h for fast metabolizers and 9.76 L/h for slow metabolizers. Pyrazinamide's clearance was more variable among hospitalized patients. The variability in clearance among patients was 1.70 and 3.56 times more for hospitalized survivors and hospitalized deaths, respectively, than outpatients. Conclusions We showed that the pharmacokinetics of first-line TB drugs are not substantially different between hospitalized TB/HIV patients and TB (with or without HIV) outpatients. Hospitalized patients do not seem to be underexposed compared to their outpatient counterparts, as well as hospitalized patients who survived vs who died within 12 weeks of hospitalization.
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Affiliation(s)
- Noha Abdelgawad
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - David Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, University of Liverpool, Liverpool, L3 5QA, UK
| | - Amy Ward
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Saskia Janssen
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, 19268, The Netherlands
| | - Rosie Burton
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Khayelitsha Hospital, Department of Medicine, Khayelitsha, 7784, South Africa
| | - Robert J. Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
- The Francis Crick Institute, London, NW1 1AT, UK
| | - Muki Shey
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
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8
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van Heerden JK, Meintjes G, Barr D, Zhao Y, Griesel R, Keene CM, Wiesner L, Galileya LT, Denti P, Maartens G. Relationship Between Tenofovir Diphosphate Concentrations in Dried Blood Spots and Virological Outcomes After Initiating Tenofovir-Lamivudine-Dolutegravir as First-Line or Second-Line Antiretroviral Therapy. J Acquir Immune Defic Syndr 2024; 95:260-267. [PMID: 38408216 PMCID: PMC7615802 DOI: 10.1097/qai.0000000000003341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/23/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Tenofovir diphosphate (TFV-DP) concentration in dried blood spots is a marker of long-term adherence. We investigated the relationship between TFV-DP concentrations and virological outcomes in participants initiating tenofovir-lamivudine-dolutegravir (TLD) as first-line or second-line antiretroviral therapy. SETTING Three primary care clinics in Khayelitsha, Cape Town, South Africa. METHODS We conducted a post hoc analysis of 2 randomized controlled trials of participants initiating TLD. TFV-DP concentrations and viral loads were measured at 12, 24, and 48 weeks. Multivariable logistic regression was performed to assess the association with virological suppression (<50 copies/mL) per natural logarithm increase in TFV-DP concentration. Generalized estimating equations with logit link were used to assess associations with virological rebound. The Akaike Information Criterion and Quasi-likelihood Information Criteria were used to compare models built on continuous TFV-DP data to 4 previously defined concentration categories. RESULTS We included 294 participants in the analysis, 188 (64%) of whom initiated TLD as second-line therapy. Adjusted odds ratios (95% CIs) of virological suppression were 2.12 (1.23, 3.75), 3.11 (1.84, 5.65), and 4.69 (2.81, 8.68) per natural logarithm increase in TFV-DP concentration at weeks 12, 24, and 48, respectively. In participants with virological suppression at week 12, the adjusted odds ratio for remaining virologically suppressed was 3.63 (95% CI: 2.21 to 5.69) per natural logarithm increase in TFV-DP concentration. Models using continuous TFV-DP data had lower Akaike Information Criterion and Quasi-likelihood Information Criteria values than those using categorical data for predicting virological outcomes. CONCLUSION TFV-DP concentrations in dried blood spots exhibit a dose-response relationship with viral load. Analyzing TFV-DP concentrations as continuous variables rather than conventional categorization may be appropriate.
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Affiliation(s)
- Jennifer Kate van Heerden
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - David Barr
- NHS Greater Glasgow and Clyde, Scotland, United Kingdom and Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Ying Zhao
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Rulan Griesel
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Claire Marriott Keene
- Médecins Sans Frontières, Cape Town, South Africa
- Health Systems Collaborative, NDM Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lufina Tsirizani Galileya
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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9
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Mpofu R, Kawuma AN, Wasmann RE, Akpomiemie G, Chandiwana N, Sokhela SM, Moorhouse M, Venter WDF, Denti P, Wiesner L, Post FA, Haas DW, Maartens G, Sinxadi P. Determinants of early change in serum creatinine after initiation of dolutegravir-based antiretroviral therapy in South Africa. Br J Clin Pharmacol 2024. [PMID: 38332460 DOI: 10.1111/bcp.16009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 02/10/2024] Open
Abstract
AIMS Dolutegravir increases serum creatinine by inhibiting its renal tubular secretion and elimination. We investigated determinants of early changes in serum creatinine in a southern African cohort starting first-line dolutegravir-based antiretroviral therapy (ART). METHODS We conducted a secondary analysis of data from participants in a randomized controlled trial of dolutegravir, emtricitabine and tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide fumarate (TAF) (ADVANCE, NCT03122262). We assessed clinical, pharmacokinetic and genetic factors associated with change in serum creatinine from baseline to Week 4 using linear regression models adjusted for age, sex, baseline serum creatinine, HIV-1 RNA concentration, CD4 T-cell count, total body weight and co-trimoxazole use. RESULTS We included 689 participants, of whom 470 had pharmacokinetic data and 315 had genetic data. Mean change in serum creatinine was 11.3 (SD 9.9) μmol.L-1 . Factors that were positively associated with change in serum creatinine at Week 4 were increased log dolutegravir area under the 24-h concentration-time curve (change in creatinine coefficient [β] = 2.78 μmol.L-1 [95% confidence interval (CI) 0.54, 5.01]), TDF use (β = 2.30 [0.53, 4.06]), male sex (β = 5.20 [2.92, 7.48]), baseline serum creatinine (β = -0.22 [-0.31, -0.12]) and UGT1A1 rs929596 A→G polymorphism with a dominant model (β = -2.33 [-4.49, -0.17]). The latter did not withstand correction for multiple testing. CONCLUSIONS Multiple clinical and pharmacokinetic factors were associated with early change in serum creatinine in individuals initiating dolutegravir-based ART. UGT1A1 polymorphisms may play a role, but further research on genetic determinants is needed.
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Affiliation(s)
- Rephaim Mpofu
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Aida N Kawuma
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Roeland E Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Godspower Akpomiemie
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nomathemba Chandiwana
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Simiso Mandisa Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michelle Moorhouse
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Frank A Post
- King's College Hospital NHS Foundation Trust, London, UK
| | - David W Haas
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Internal Medicine, Meharry Medical College, Nashville, Tennessee, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- SAMRC/UCT Platform for Pharmacogenomics Research and Translation (PREMED) unit, Cape Town, South Africa
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10
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Combrinck J, Tshavhungwe P, Rohlwink U, Enslin N, Thango N, Lazarus J, Kriegler K, Castel S, Abdelgawad N, Mcilleron H, Denti P, Wiesner L, Figaji A. Rifampicin and protein concentrations in paired spinal versus ventricular cerebrospinal fluid samples of children with tuberculous meningitis. J Antimicrob Chemother 2024; 79:280-286. [PMID: 38101948 PMCID: PMC10832594 DOI: 10.1093/jac/dkad371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/18/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is the most lethal form of TB. To study the disease, drug concentrations in samples obtained from the spinal CSF are usually used to reflect brain concentrations. Emerging data suggest that transport of substances across capillaries in the brain (ventricular CSF) and spinal cord may differ. METHODS We examined paired, time-linked samples of ventricular CSF (VCSF) and lumbar CSF (LCSF) of 28 patients with TBM and analysed these for rifampicin and total protein concentrations. Clinically indicated samples from procedures to determine the level of CSF block were collected from children being treated for TBM and hydrocephalus. Total protein concentrations were determined using the bicinchoninic acid (BCA) or turbidimetry assay, and rifampicin concentrations were determined using a validated LC coupled with tandem MS method. A paired Wilcoxon signed-rank test was used to determine significance. RESULTS TBM was confirmed in 19 cases (68%) using TB culture or GeneXpert Mtb/Rifampicin assay. All other cases were classified as probable. The median total protein concentration in LCSF was 6.0 g/L and in VCSF was 1.3 g/L. The median rifampicin concentration in LCSF was 299 ng/mL and 133 ng/mL in VCSF. The median ratio of LCSF/VSCF for protein was 4.23 and 1.57 for rifampicin. CONCLUSIONS Total protein and rifampicin concentrations differed significantly between the two compartments, both being higher in LCSF than in VCSF samples (P < 0.0001 for total protein and P = 0.0046 for rifampicin). Further studies are required to explore the causative reasons for the observed differences.
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Affiliation(s)
- Jill Combrinck
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Phophi Tshavhungwe
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Ursula Rohlwink
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Nico Enslin
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Nqobile Thango
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Jed Lazarus
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Katie Kriegler
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Noha Abdelgawad
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen Mcilleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anthony Figaji
- Division of Paediatric Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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11
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Ali AM, P. Solans B, Hesseling AC, Winckler J, Schaaf HS, Draper HR, van der Laan L, Hughes J, Fourie B, Nielsen J, Wiesner L, Garcia-Prats AJ, Savic RM. Pharmacokinetics and cardiac safety of clofazimine in children with rifampicin-resistant tuberculosis. Antimicrob Agents Chemother 2024; 68:e0079423. [PMID: 38112526 PMCID: PMC10777824 DOI: 10.1128/aac.00794-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/18/2023] [Indexed: 12/21/2023] Open
Abstract
Clofazimine is recommended for the treatment of rifampicin-resistant tuberculosis (RR-TB), but there is currently no verified dosing guideline for its use in children. There is only limited safety and no pharmacokinetic (PK) data available for children. We aimed to characterize clofazimine PK and its relationship with QT-interval prolongation in children. An observational cohort study of South African children <18 years old routinely treated for RR-TB with a clofazimine-containing regimen was analyzed. Clofazimine 100 mg gelatin capsules were given orally once daily (≥20 kg body weight), every second day (10 to <20 kg), or thrice weekly (<10 kg). PK sampling and electrocardiograms were completed pre-dose and at 1, 4, and 10 hours post-dose, and the population PK and Fridericia-corrected QT (QTcF) interval prolongation were characterized. Fifty-four children contributed both PK and QTcF data, with a median age (2.5th-97.5th centiles) of 3.3 (0.5-15.6) years; five children were living with HIV. Weekly area under the time-concentration curve at steady state was 79.1 (15.0-271) mg.h/L compared to an adult target of 60.9 (56.0-66.6) mg.h/L. Children living with HIV had four times higher clearance compared to those without. No child had a QTcF ≥500 ms. A linear concentration-QTcF relationship was found, with a drug effect of 0.05 (0.027, 0.075) ms/µg/L. In some of the first PK data in children, we found clofazimine exposure using an off-label dosing strategy was higher in children versus adults. Clofazimine concentrations were associated with an increase in QTcF, but severe prolongation was not observed. More data are required to inform dosing strategies in children.
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Affiliation(s)
- Ali Mohamed Ali
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
- Department of Interventions and Clinical Trials, Bagamoyo Research and Training Center, Ifakara Health Institute, Bagamoyo, Tanzania
| | - Belén P. Solans
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Anneke C. Hesseling
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jana Winckler
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - H. Simon Schaaf
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Heather R. Draper
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Louvina van der Laan
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jennifer Hughes
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Barend Fourie
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James Nielsen
- Department of Pediatrics, New York University School of Medicine, New York, New York, USA
| | - Lubbe Wiesner
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Anthony J. Garcia-Prats
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Pediatrics, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Radojka M. Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
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12
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Watson DJ, Laing L, Petzer JP, Wong HN, Parkinson CJ, Wiesner L, Haynes RK. Efficacies and ADME properties of redox active methylene blue and phenoxazine analogues for use in new antimalarial triple drug combinations with amino-artemisinins. Front Pharmacol 2024; 14:1308400. [PMID: 38259296 PMCID: PMC10800708 DOI: 10.3389/fphar.2023.1308400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024] Open
Abstract
Efforts to develop new artemisinin triple combination therapies effective against artemisinin-tolerant strains of Plasmodium falciparum based on rational combinations comprising artemisone or other amino-artemisinins, a redox active drug and a third drug with a different mode of action have now been extended to evaluation of three potential redox partners. These are the diethyl analogue AD01 of methylene blue (MB), the benzo [α]phenoxazine PhX6, and the thiosemicarbazone DpNEt. IC50 values in vitro against CQ-sensitive and resistant P. falciparum strains ranged from 11.9 nM for AD01-41.8 nM for PhX6. PhX6 possessed the most favourable pharmacokinetic (PK) profile: intrinsic clearance rate CLint was 21.47 ± 1.76 mL/min/kg, bioavailability was 60% and half-life was 7.96 h. AD01 presented weaker, but manageable pharmacokinetic properties with a rapid CLint of 74.41 ± 6.68 mL/min/kg leading to a half-life of 2.51 ± 0.07 h and bioavailability of 15%. DpNEt exhibited a half-life of 1.12 h and bioavailability of 8%, data which discourage its further examination, despite a low CLint of 10.20 mL/min/kg and a high Cmax of 6.32 µM. Efficacies of AD01 and PhX6 were enhanced synergistically when each was paired with artemisone against asexual blood stages of P. falciparum NF54 in vitro. The favourable pharmacokinetics of PhX6 indicate this is the best partner among the compounds examined thus far for artemisone. Future work will focus on extending the drug combination studies to artemiside in vitro, and conducting efficacy studies in vivo for artemisone with each of PhX6 and the related benzo[α]phenoxazine SSJ-183.
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Affiliation(s)
- Daniel J. Watson
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lizahn Laing
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jacobus P. Petzer
- Centre of Excellence for Pharmaceutical Sciences, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Ho Ning Wong
- Rural Health Research Institute, Charles Sturt University, Orange, NSW, Australia
| | | | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Richard K. Haynes
- Centre of Excellence for Pharmaceutical Sciences, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
- Rural Health Research Institute, Charles Sturt University, Orange, NSW, Australia
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13
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Mkhize B, Court R, Castel S, Joubert A, van der Merwe M, Wiesner L. Development and validation of a liquid chromatography tandem mass spectrometry assay for the analysis of bedaquiline and M2 in breast milk. J Mass Spectrom Adv Clin Lab 2024; 31:8-16. [PMID: 38188986 PMCID: PMC10770620 DOI: 10.1016/j.jmsacl.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/28/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
Objective To develop and validate an assay for the analysis of bedaquiline and its M2 metabolite in human breast milk. Methods The analytes were extracted using solid phase extraction following protein precipitation. Quantification was performed with liquid chromatography coupled with tandem mass spectrometry. Chromatographic separation was achieved using gradient chromatography on a Poroshell 120 SB-C18 analytical column at 40 °C, with a flow rate of 350 µL/minute and a total run time of eight minutes. An AB Sciex 3000 mass spectrometer with electrospray ionization in the positive mode was used for detection, employing multiple reaction monitoring scan mode. Bedaquiline-d6 and M2-d3-13C were used as internal standards. Results Calibrations curves for bedaquiline and M2 exhibited quadratic (weighted 1/x concentration) regressions over the respective concentration ranges of 0.0780 to 5.00 µg/mL and 0.0312 to 2.00 µg/mL. Inter- and intra-day validation accuracies ranged between 96.7 % and 103.5 % for bedaquiline, and 104.2 % to 106.5 % for M2, with a coefficient of variation below 9.2 % for both compounds. Conclusion The developed assay demonstrated selectivity and robustness, enabling differentiation between bedaquiline and M2 within the context of endogenous compounds from six separate lots of breast milk samples. Successful application was observed in the analysis of breast milk samples sourced from patients treated for multidrug-resistant tuberculosis within a clinical study setting.
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Affiliation(s)
- Buyisile Mkhize
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Richard Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marthinus van der Merwe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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14
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van der Laan LE, Garcia-Prats AJ, McIlleron H, Abdelwahab MT, Winckler JL, Draper HR, Wiesner L, Schaaf HS, Hesseling AC, Denti P. Optimizing dosing of the cycloserine pro-drug terizidone in children with rifampicin-resistant tuberculosis. Antimicrob Agents Chemother 2023; 67:e0061123. [PMID: 37971239 PMCID: PMC10720412 DOI: 10.1128/aac.00611-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/07/2023] [Indexed: 11/19/2023] Open
Abstract
There are no pharmacokinetic data in children on terizidone, a pro-drug of cycloserine and a World Health Organization (WHO)-recommended group B drug for rifampicin-resistant tuberculosis (RR-TB) treatment. We collected pharmacokinetic data in children <15 years routinely receiving 15-20 mg/kg of daily terizidone for RR-TB treatment. We developed a population pharmacokinetic model of cycloserine assuming a 2-to-1 molecular ratio between terizidone and cycloserine. We included 107 children with median (interquartile range) age and weight of 3.33 (1.55, 5.07) years and 13.0 (10.1, 17.0) kg, respectively. The pharmacokinetics of cycloserine was described with a one-compartment model with first-order elimination and parallel transit compartment absorption. Allometric scaling using fat-free mass best accounted for the effect of body size, and clearance displayed maturation with age. The clearance in a typical 13 kg child was estimated at 0.474 L/h. The mean absorption transit time when capsules were opened and administered as powder was significantly faster compared to when capsules were swallowed whole (10.1 vs 72.6 min) but with no effect on bioavailability. Lower bioavailability (-16%) was observed in children with weight-for-age z-score below -2. Compared to adults given 500 mg daily terizidone, 2022 WHO-recommended pediatric doses result in lower exposures in weight bands 3-10 kg and 36-46 kg. We developed a population pharmacokinetic model in children for cycloserine dosed as terizidone and characterized the effects of body size, age, formulation manipulation, and underweight-for-age. With current terizidone dosing, pediatric cycloserine exposures are lower than adult values for several weight groups. New optimized dosing is suggested for prospective evaluation.
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Affiliation(s)
- Louvina E. van der Laan
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anthony J. Garcia-Prats
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mahmoud T. Abdelwahab
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jana L. Winckler
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Heather R. Draper
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - H. Simon Schaaf
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anneke C. Hesseling
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Mwita JC, Joubert A, Saidu H, Sani MU, Damasceno A, Mocumbi AO, Sinxadi P, Viljoen CA, Hoevelmann J, Gebreyesus MS, Denti P, Wasmann R, Maartens G, Wiesner L, Stewart S, Davison B, Cotter G, Sliwa K. Objectively measured medication adherence using assays for carvedilol and enalaprilat in patients with heart failure in Mozambique and Nigeria. Int J Cardiol Cardiovasc Risk Prev 2023; 19:200213. [PMID: 37811486 PMCID: PMC10556761 DOI: 10.1016/j.ijcrp.2023.200213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 10/10/2023]
Abstract
Background Poor medication adherence leads to poor health outcomes and increased healthcare costs among patients with heart failure (HF). This study aimed to objectively assess medication adherence by measuring carvedilol and enalaprilat plasma concentrations among patients with HF. Methods The present sub-study of the Safety, Tolerability, and Efficacy of Rapid Optimization, helped by NT-proBNP testing, of Heart Failure therapies (STRONG-HF) study involved adult patients with acute HF admitted in two Mozambican and two Nigerian hospitals who were not optimally treated with oral enalapril and carvedilol. Patients in the high-intensity arm of the STRONG-HF study, and those not meeting the biomarker criteria for persistent congestion, were included in the "frequent visit" (FV) arm. In the FV arm, blood for bioanalysis of plasma enalaprilat or/and carvedilol was drawn at the 2,6,12th week post-discharge. Patients in the usual care arm of STRONG-HF were included in the "standard visit" (SV) arm, which followed the usual local practice with blood sampling in week 12. Results The study involved 113 (79 FV and 34 SV) participants with a mean age of 48.6 years and a mean left ventricular (LV) ejection fraction of 33.1%. Theenalaprilat below the lower level of quantification (LLOQ) was documented in 7.7%, 11.9%, and 15.6% of participants in FV during the 2,6 and 12th weeks. Carvedilol concentration below LLOQ was documented in 37%, 30%, and 44.4% of participants in the FV arm during the 2,6 and 12th weeks, respectively. For the SV arm, enalaprilat and carvedilol concentrations below LLOQ in the twelfth week were documented in 37.3% and 42.9% of patients, respectively. Conclusion Up to a third of patients using enalapril and carvedilol did not take any medication during the 12 weeks of follow-up. Non adherence was more common in patients who had less follow up, emphasizing the importance of close follow up to adherence. No adherence was also more common in medications know to have more side effects such as carvedilol.
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Affiliation(s)
- Julius Chacha Mwita
- Department of Internal Medicine, University of Botswana and Princess Marina Hospital, Gaborone, Botswana
| | - Andre Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Hadiza Saidu
- Department of Medicine Bayero University Kano & Murtala Muhammed Specialist Hospital, Kano, Nigeria
| | - Mahmoud Umar Sani
- Department of Medicine, Bayero University Kano & Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Albertino Damasceno
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- Research Unit, Department of Medicine, Maputo Central Hospital, Maputo, Mozambique
| | - Ana Olga Mocumbi
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- Instituto Nacional de Saúde, Vila de Marracuene, Mozambique
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- SAMRC/UCT Platform for Pharmacogenomics Research and Translation, South African Medical Research Council, Cape Town, South Africa
| | - Charle Andre Viljoen
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Julian Hoevelmann
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Internal Medicine III - Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital, Homburg, Germany
| | - Manna Semere Gebreyesus
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Roeland Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Simon Stewart
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
- Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Beth Davison
- Momentum Research, Inc., Chapel Hill, NC, USA
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France
| | - Gad Cotter
- Momentum Research, Inc., Chapel Hill, NC, USA
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France
| | - Karen Sliwa
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Gausi K, Mugerwa H, Siccardi M, Montanha MC, Lamorde M, Wiesner L, D'Avolio A, McIlleron H, Wilkins E, De Nicolò A, Maartens G, Khoo S, Kityo C, Denti P, Waitt C. Pharmacokinetics and safety of twice-daily ritonavir-boosted atazanavir with rifampicin. Clin Infect Dis 2023:ciad700. [PMID: 37982585 DOI: 10.1093/cid/ciad700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/24/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND Critical drug-drug interactions (DDI) and hepatotoxicity complicate concurrent use of rifampicin and protease inhibitors. We investigated whether dose escalation of atazanavir/ritonavir could safely overcome the DDI with rifampicin. METHODS DERIVE (NCT04121195, EDCTP) was a dose-escalation trial in people with HIV on atazanavir/ritonavir-based ART in Uganda. Four intensive pharmacokinetic (PK) visits were performed: PK1 300/100 mg OD (baseline); PK2 300/100 mg OD with rifampicin 600 mg; PK3 300/100 mg BID with rifampicin 600 mg OD; PK4 300/100 mg BID with rifampicin 1200 mg OD. Dolutegravir 50 mg BID throughout the study period ensured participants remained protected from subtherapeutic atazanavir concentrations. The data was interpreted with noncompartmental analysis. The target minimum concentration was atazanavir's protein-adjusted IC90 (PA-IC90), 0.014 mg/L. RESULTS We enrolled 26 participants (23 female) with median (range) age 44 (28-61) years and weight 67 (50-75) kg. Compared with PK1, atazanavir Ctau, and AUC were significantly reduced at PK2 by 96% and 85%, respectively. The escalation to BID dosing (PK3) reduced this difference in Ctau, and AUC24 to 18% lower and 8% higher, respectively. Comparable exposures were maintained with double doses of rifampicin. Lowest Ctau during PK1, PK3, and PK4 were 12.7-, 4.8-, and 8.6-fold higher than PA-IC90, respectively, while 65% of PK2 Ctau were below the limit of quantification (0.03 mg/L), hence likely below PA-IC90. No participant developed significant elevation of liver enzymes, reported an SAE, or experienced rebound viraemia. CONCLUSIONS Twice daily atazanavir/ritonavir during rifampicin co-administration was well-tolerated and achieved plasma concentrations above the target.
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Affiliation(s)
- Kamunkhwala Gausi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | | | - Marco Siccardi
- Department of Pharmacology and Therapeutics, University of Liverpool, United Kingdom
| | | | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Uganda
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Antonio D'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Italy
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Ed Wilkins
- North Manchester General Hospital, United Kingdom
| | - Amedeo De Nicolò
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Italy
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Saye Khoo
- Department of Pharmacology and Therapeutics, University of Liverpool, United Kingdom
| | - Cissy Kityo
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Catriona Waitt
- Department of Pharmacology and Therapeutics, University of Liverpool, United Kingdom
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Van Schalkwyk M, Bekker A, Decloedt E, Wang J, Theron GB, Cotton MF, Eke AC, Cressey TR, Shapiro DE, Bacon K, Knowles K, George K, Browning R, Chakhtoura N, Rungruengthanakit K, Wiesner L, Capparelli EV, Stek AM, Mirochnick M, Best BM. Pharmacokinetics and safety of first-line tuberculosis drugs rifampin, isoniazid, ethambutol, and pyrazinamide during pregnancy and postpartum: results from IMPAACT P1026s. Antimicrob Agents Chemother 2023; 67:e0073723. [PMID: 37882552 PMCID: PMC10648924 DOI: 10.1128/aac.00737-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/14/2023] [Indexed: 10/27/2023] Open
Abstract
Physiological changes during pregnancy may alter the pharmacokinetics (PK) of antituberculosis drugs. The International Maternal Pediatric Adolescent AIDS Clinical Trials Network P1026s was a multicenter, phase IV, observational, prospective PK and safety study of antiretroviral and antituberculosis drugs administered as part of clinical care in pregnant persons living with and without HIV. We assessed the effects of pregnancy on rifampin, isoniazid, ethambutol, and pyrazinamide PK in pregnant and postpartum (PP) persons without HIV treated for drug-susceptible tuberculosis disease. Daily antituberculosis treatment was prescribed following World Health Organization-recommended weight-band dosing guidelines. Steady-state 12-hour PK profiles of rifampin, isoniazid, ethambutol, and pyrazinamide were performed during second trimester (2T), third trimester (3T), and 2-8 of weeks PP. PK parameters were characterized using noncompartmental analysis, and comparisons were made using geometric mean ratios (GMRs) with 90% confidence intervals (CI). Twenty-seven participants were included: 11 African, 9 Asian, 3 Hispanic, and 4 mixed descent. PK data were available for 17, 21, and 14 participants in 2T, 3T, and PP, respectively. Rifampin and pyrazinamide AUC0-24 and C max in pregnancy were comparable to PP with the GMR between 0.80 and 1.25. Compared to PP, isoniazid AUC0-24 was 25% lower and C max was 23% lower in 3T. Ethambutol AUC0-24 was 39% lower in 3T but limited by a low PP sample size. In summary, isoniazid and ethambutol concentrations were lower during pregnancy compared to PP concentrations, while rifampin and pyrazinamide concentrations were similar. However, the median AUC0-24 for rifampin, isoniazid, and pyrazinamide met the therapeutic targets. The clinical impact of lower isoniazid and ethambutol exposure during pregnancy needs to be determined.
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Affiliation(s)
- Marije Van Schalkwyk
- Division of Adult Infectious Diseases, Department of Medicine, Family Centre for Research with Ubuntu, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Adrie Bekker
- Department of Pediatrics and Child Health, Family Centre for Research with Ubuntu, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Jiajia Wang
- Department of Biostatistics, Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Gerhard B. Theron
- Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa
| | - Mark F. Cotton
- Department of Pediatrics and Child Health, Family Centre for Research with Ubuntu, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Ahizechukwu C. Eke
- Division of Maternal Fetal Medicine and Clinical Pharmacology, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tim R. Cressey
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - David E. Shapiro
- Department of Biostatistics, Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kira Bacon
- Frontier Science Foundation, Amherst, New York, USA
| | | | | | - Renee Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
| | - Nahida Chakhtoura
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland, USA
| | | | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Edmund V. Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, California, USA
- Department of Pediatrics, School of Medicine, University of California, San Diego, California, USA
| | - Alice M. Stek
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, California, USA
| | - Mark Mirochnick
- Division of Neonatology, Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, California, USA
- Department of Pediatrics, School of Medicine, University of California, San Diego, California, USA
| | - on behalf of the IMPAACT P1026s Protocol Team
- Division of Adult Infectious Diseases, Department of Medicine, Family Centre for Research with Ubuntu, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
- Department of Pediatrics and Child Health, Family Centre for Research with Ubuntu, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
- Department of Biostatistics, Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa
- Division of Maternal Fetal Medicine and Clinical Pharmacology, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Frontier Science Foundation, Amherst, New York, USA
- FHI 360, Durham, North Carolina, USA
- Division of AIDS, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, Maryland, USA
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, California, USA
- Department of Pediatrics, School of Medicine, University of California, San Diego, California, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, California, USA
- Division of Neonatology, Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
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Mazanhanga M, Joubert A, Castel S, Van de Merwe M, Maartens G, Wasserman S, Wiesner L. Validation of a quantitative liquid chromatography tandem mass spectrometry assay for linezolid in cerebrospinal fluid and its application to patients with HIV-associated TB-meningitis. Heliyon 2023; 9:e21962. [PMID: 38034739 PMCID: PMC10685187 DOI: 10.1016/j.heliyon.2023.e21962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/25/2023] [Accepted: 11/01/2023] [Indexed: 12/02/2023] Open
Abstract
Tuberculous meningitis treatment outcomes are poor and alternative regimens are under investigation. Reliable methods to measure drug concentrations in cerebrospinal fluid are required to evaluate distribution into the cerebrospinal fluid. A simple and quick method was developed and validated to analyse linezolid in human cerebrospinal fluid. Samples were prepared by protein precipitation followed by isocratic liquid chromatography and tandem mass spectrometry. The run time was 3.5 min. Accuracy and precision were assessed in three independent validation batches with a calibration range of 0.100-20.0 μg/mL. The method was used to analyse cerebrospinal fluid samples from patients with tuberculous meningitis enrolled in a clinical trial. Potentially infective patient samples could be decontaminated using Nanosep® nylon and Costar® nylon filter tubes under biosafety level 3 conditions before analysis. The filtration process did not significantly affect the quantification of linezolid. Linezolid concentration in cerebrospinal fluid obtained from tuberculous meningitis patients ranged from 0.197 μg/mL to 15.0 μg/mL. The ratio between average CSF and plasma linezolid concentrations varied with time, reaching a maximum of 0.9 at 6 h after dosing.
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Affiliation(s)
- Marian Mazanhanga
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marthinus Van de Merwe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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van der Laan LE, Hesseling AC, Schaaf HS, Palmer M, Draper HR, Wiesner L, Denti P, Garcia-Prats AJ. Pharmacokinetics and optimized dosing of dispersible and non-dispersible levofloxacin formulations in young children. J Antimicrob Chemother 2023; 78:2481-2488. [PMID: 37596982 PMCID: PMC10545503 DOI: 10.1093/jac/dkad257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/31/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND Levofloxacin is used for treatment and prevention of rifampicin-resistant (RR)-TB in children. Recent data showed higher exposures with 100 mg dispersible compared with non-dispersible tablet formulations with potentially important dosing implications in children. We aimed to verify and better characterize this finding. METHODS We conducted a crossover pharmacokinetic trial in children aged ≤5 years receiving levofloxacin RR-TB preventive therapy. Pharmacokinetic sampling was done after 15-20 mg/kg doses of levofloxacin with 100 mg dispersible and crushed 250 mg non-dispersible levofloxacin formulations. A population pharmacokinetic model was developed. RESULTS Twenty-five children were included, median (IQR) weight and age 12.2 (10.7-15.0) kg and 2.56 (1.58-4.03) years, respectively. A two-compartment model with first-order elimination and transit compartment absorption best described levofloxacin pharmacokinetics. Allometric scaling adjusted for body size, and maturation of clearance with age was characterized. Typical clearance in a 12 kg child was estimated at 4.17 L/h. Non-dispersible tablets had 21.5% reduced bioavailability compared with the dispersible formulation, with no significant differences in other absorption parameters.Dosing simulations showed that current recommended dosing for both formulations result in median exposures below adult-equivalent exposures at a 750 mg daily dose, mainly in children >6 months. Higher levofloxacin doses of 16-30 mg/kg for dispersible and 20-38 mg/kg for crushed non-dispersible tablets may be required in children >6 months. CONCLUSIONS The dispersible paediatric levofloxacin formulation has improved bioavailability compared with the crushed non-dispersible adult formulation, but exposures remain below those in adults. We propose optimized age- and weight-based dosing for levofloxacin, which require further evaluation.
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Affiliation(s)
- Louvina E van der Laan
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Megan Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Heather R Draper
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anthony J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- University of Wisconsin-Madison, School of Medicine and Public Health, Madison, WI, USA
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20
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Waalewijn H, Szubert AJ, Wasmann RE, Wiesner L, Chabala C, Bwakura-Dangarembizi M, Makumbi S, Nangiya J, Mumbiro V, Mulenga V, Musiime V, Monkiewicz LN, Griffiths AL, Bamford A, Doerholt K, Denti P, Burger DM, Gibb DM, McIlleron HM, Colbers A. First Pharmacokinetic Data of Tenofovir Alafenamide Fumarate and Tenofovir With Dolutegravir or Boosted Protease Inhibitors in African Children: A Substudy of the CHAPAS-4 Trial. Clin Infect Dis 2023; 77:875-882. [PMID: 37315296 PMCID: PMC10506774 DOI: 10.1093/cid/ciad267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND We evaluated the pharmacokinetics of tenofovir alafenamide fumarate (TAF) and tenofovir in a subset of African children enrolled in the CHAPAS-4 trial. METHODS Children aged 3-15 years with human immunodeficiency virus infection failing first-line antiretroviral therapy were randomized to emtricitabine/TAF versus standard-of-care nucleoside reverse transcriptase inhibitor combination, plus dolutegravir, atazanavir/ritonavir, darunavir/ritonavir, or lopinavir/ritonavir. Daily emtricitabine/TAF was dosed according to World Health Organization (WHO)-recommended weight bands: 120/15 mg in children weighing 14 to <25 kg and 200/25 mg in those weighing ≥25 kg. At steady state, 8-9 blood samples were taken to construct pharmacokinetic curves. Geometric mean (GM) area under the concentration-time curve (AUC) and the maximum concentration (Cmax) were calculated for TAF and tenofovir and compared to reference exposures in adults. RESULTS Pharmacokinetic results from 104 children taking TAF were analyzed. GM (coefficient of variation [CV%]) TAF AUClast when combined with dolutegravir (n = 18), darunavir/ritonavir (n = 34), or lopinavir/ritonavir (n = 20) were 284.5 (79), 232.0 (61), and 210.2 (98) ng*hour/mL, respectively, and were comparable to adult reference values. When combined with atazanavir/ritonavir (n = 32), TAF AUClast increased to 511.4 (68) ng*hour/mL. For each combination, tenofovir GM (CV%) AUCtau and Cmax remained below reference values in adults taking 25 mg TAF with a boosted protease inhibitors. CONCLUSIONS In children, TAF combined with boosted PIs or dolutegravir and dosed according to WHO-recommended weight bands provides TAF and tenofovir concentrations previously demonstrated to be well tolerated and effective in adults. These data provide the first evidence for use of these combinations in African children. CLINICAL TRIALS REGISTRATION ISRCTN22964075.
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Affiliation(s)
- Hylke Waalewijn
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Alexander J Szubert
- Medical Research Council Clinical Trials Unit, University College London, United Kingdom
| | - Roeland E Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Chishala Chabala
- Department of Paediatrics and Child Health, School of Medicine, University of Zambia
- Children’s Hospital, University Teaching Hospital, Lusaka, Zambia
| | | | - Shafic Makumbi
- Joint Clinical Research Centre, Mbarara Regional Centre of Excellence, Mbarara, Uganda
| | - Joan Nangiya
- Joint Clinical Research Centre, Research Department, Kampala, Uganda
| | | | - Veronica Mulenga
- Children’s Hospital, University Teaching Hospital, Lusaka, Zambia
| | - Victor Musiime
- Joint Clinical Research Centre, Research Department, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Lara N Monkiewicz
- Medical Research Council Clinical Trials Unit, University College London, United Kingdom
| | - Anna L Griffiths
- Medical Research Council Clinical Trials Unit, University College London, United Kingdom
| | - Alasdair Bamford
- Medical Research Council Clinical Trials Unit, University College London, United Kingdom
- Infection, Immunity & Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Katja Doerholt
- Medical Research Council Clinical Trials Unit, University College London, United Kingdom
- Paediatric Infectious Diseases Unit, St George's University Hospital, London, United Kingdom
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - David M Burger
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit, University College London, United Kingdom
| | - Helen M McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Angela Colbers
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
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Mthethwa M, Jeebhay M, Olaniyan T, Wiesner L, Parker B, Leaner J, Röösli M, Dalvie MA. The Association Between Urinary Concentrations of Organophosphate Metabolites and Asthma-Related Outcomes Among Schoolchildren From Informal Settlements. Int J Public Health 2023; 68:1606174. [PMID: 37674664 PMCID: PMC10477361 DOI: 10.3389/ijph.2023.1606174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 08/11/2023] [Indexed: 09/08/2023] Open
Abstract
Objectives: There is inconsistent evidence on the relationship between pesticide exposure and childhood respiratory outcomes in non-agricultural settings. This study investigated the association between organophosphate (OP) pesticide exposure and asthma-related outcomes in children residing in four informal settlements. Methods: The study was a longitudinal study of 590 schoolchildren, with a 12 months follow-up period. A standardised questionnaire adopted from the International Study of Asthma and Allergies in Childhood was administered to caregivers for child's respiratory symptoms and household characteristics. Spirometry and fractional-exhaled nitric oxide, including a phadiatop test (atopy status) and urinary dialkyl phosphate (DAP) metabolites were measured at baseline and follow-up. DAP metabolites included diethylphosphate (DEP) and dimethyl phosphate (DMP) measured at baseline and follow-up and dimethylthiophosphate (DMTP) measured only at baseline. Results: The mean ages of schoolchildren were 9.9 ± 0.91 years and the overal incidence proportions of new doctor diagnosed asthma was 2.2%. No consistent patterns of increased risk of asthma outcomes with increasing DAP concentrations was found in multivariate analysis. Conclusion: Future studies with longer follow-up periods and repeated OP biomonitoring are recommended.
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Affiliation(s)
- Mashudu Mthethwa
- Centre for Environmental and Occupational Health Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mohamed Jeebhay
- Centre for Environmental and Occupational Health Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Occupational Medicine, University of Cape Town, Cape Town, South Africa
| | - Toyib Olaniyan
- Centre for Environmental and Occupational Health Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Bhawoodien Parker
- Department of Environmental Affairs and Developmental Planning, Western Cape Government, Cape Town, South Africa
| | - Joy Leaner
- Department of Environmental Affairs and Developmental Planning, Western Cape Government, Cape Town, South Africa
| | - Martin Röösli
- Swiss Tropical Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Mohamed Aqiel Dalvie
- Centre for Environmental and Occupational Health Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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22
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Arnab P, Croxford R, Scott J, Perumal S, Mohammed Z, Wiesner L, Cohen K, Wasserman S. Severe efavirenz associated neurotoxicity: A retrospective cohort study. S Afr J Infect Dis 2023; 38:522. [PMID: 37780199 PMCID: PMC10397354 DOI: 10.4102/sajid.v38i1.522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/09/2023] [Indexed: 10/03/2023] Open
Abstract
Background Efavirenz (EFV) is associated with neuropsychiatric symptoms. Severe neurotoxicity has been reported but the clinical phenotype and risk factors are poorly defined. Objectives To characterise clinical presentations, risk factors and outcomes to help clinicians recognise severe neurotoxicity earlier. Method The authors retrospectively identified adults with supratherapeutic EFV concentrations (> 4 mg/L) obtained during routine clinical care in Cape Town, South Africa. Clinical and laboratory data at the time of EFV quantification were extracted from medical records. Logistic regression was performed to identify associations with neuropsychiatric symptoms, and with severe neurotoxicity. Results Eighty one patients were included; 62 with neuropsychiatric manifestations (most frequently ataxia [n = 20] and psychomotor slowing [n = 24]); and 19 with hepatotoxicity. Overall, 28 (34.6%) were male, 49 (60.5%) had concomitant isoniazid exposure, and median EFV concentration was 12.1 mg/L (interquartile range [IQR]: 6.6-20.0). Neuropsychiatric symptoms were associated with longer duration of EFV therapy, adjusted odds ratio (aOR) 1.3/180-day increment (95% confidence interval [CI]: 1.0-1.7); higher EFV concentrations, aOR 1.2/1 mg/L increase (95% CI: 1.0-1.4) and isoniazid exposure, aOR 8.2 (95% CI: 2.5-26.7). Severe neuropsychiatric symptoms occurred in 47 (75%) patients at a median of 5.9 months (IQR: 2.1-40.8) after EFV initiation. Severe symptoms odds were 1.2-fold higher (95% CI: 1.1-1.4) per 1 mg/L increase in EFV concentration. Symptoms resolved completely within 1 month in 25 (76%) patients with severe neurotoxicity who discontinued EFV. Conclusion A concentration-effect relationship for severe neurotoxicity exists, which occurred late and resolved in most patients after EFV discontinuation. Contribution The authors highlighted clinical heterogeneity and morbidity of EFV-associated neurotoxicity.
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Affiliation(s)
- Priyadarshini Arnab
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Roland Croxford
- Department of Health, DP Marais Hospital, Western Cape Government, Cape Town, South Africa
| | - Janet Scott
- Department of Health, DP Marais Hospital, Western Cape Government, Cape Town, South Africa
| | - Sameshan Perumal
- Department of Statistics, Faculty of Sciences, University of Cape Town, Cape Town, South Africa
| | - Zahraa Mohammed
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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23
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Frederix K, Schwitters A, Chung G, McCracken S, Kupamundi T, Patel HK, Arpadi S, Domaoal RA, Ntene-Sealiete K, Thin K, Wiesner L, Low A. The state of the pediatric HIV epidemic in Lesotho. AIDS 2023; 37:1377-1386. [PMID: 37070538 DOI: 10.1097/qad.0000000000003581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVE Lesotho does not have reliable data on HIV prevalence in children, relying on estimates generated from program data. The 2016 Lesotho Population-based HIV Impact Assessment (LePHIA) aimed to determine HIV prevalence among children 0-14 years to assess the effectiveness of the prevention of mother-to-child transmission (PMTCT) program and guide future policy. METHODS A nationally representative sample of children under 15 years underwent household-based, two-stage HIV testing from November 2016-May 2017. Children <18 months with a reactive screening test were tested for HIV infection using total nucleic acid (TNA) PCR. Parents (61.1%) or legal guardians (38.9%) provided information on children's clinical history. Children aged 10-14 years also answered a questionnaire on knowledge and behaviors. RESULTS HIV prevalence was 2.1% [95% confidence interval (CI): 1.5-2.6]. Prevalence in 10-14 year olds (3.2%; 95% CI: 2.1, 4.2) was significantly greater compared to 0-4 year olds (1.0%; 95% CI: 0.5, 1.6). HIV prevalence in girls and boys was 2.6% (95% CI: 1.8-3.3) and 1.5% (95% CI: 1.0-2.1), respectively. Based on reported status and/or the presence of detectable antiretrovirals, 81.1% (95% CI: 71.7-90.4) of HIV-positive children were aware of their status, 98.2% (95% CI: 90.7-100.0) of those aware were on antiretroviral therapy (ART) and 73.9% (95% CI: 62.1-85.8) of those on ART were virally suppressed. CONCLUSIONS Despite the roll-out of Option B+ in Lesotho in 2013, pediatric HIV prevalence remains high. Further research is required to understand the greater prevalence among girls, barriers to PMTCT, and how to better achieve viral suppression in children with HIV.
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Affiliation(s)
| | - Amee Schwitters
- US Centers for Disease Control, Division of Global HIV&TB, Atlanta, Georgia
| | - Grace Chung
- ICAP at Columbia University, New York, New York
| | - Stephen McCracken
- US Centers for Disease Control, Division of Global HIV&TB, Atlanta, Georgia
| | | | - Hetal K Patel
- US Centers for Disease Control, Division of Global HIV&TB, Atlanta, Georgia
| | - Stephen Arpadi
- ICAP at Columbia University, New York, New York
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Robert A Domaoal
- US Centers for Disease Control, Division of Global HIV&TB, Atlanta, Georgia
| | | | | | - Lubbe Wiesner
- University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Andrea Low
- ICAP at Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, New York, New York, USA
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24
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Upton CM, Wiesner L, Dooley KE, Maartens G. Cerebrospinal Fluid and Tuberculous Meningitis. Clin Infect Dis 2023; 77:158. [PMID: 36987607 DOI: 10.1093/cid/ciad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Affiliation(s)
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Kelly E Dooley
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
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25
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Griesel R, Zhao Y, Simmons B, Omar Z, Wiesner L, Keene CM, Hill AM, Meintjes G, Maartens G. Standard-dose versus double-dose dolutegravir in HIV-associated tuberculosis in South Africa (RADIANT-TB): a phase 2, non-comparative, randomised controlled trial. Lancet HIV 2023; 10:e433-e441. [PMID: 37230101 PMCID: PMC10322729 DOI: 10.1016/s2352-3018(23)00081-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/14/2023] [Accepted: 04/04/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND The drug-drug interaction between rifampicin and dolutegravir can be overcome by supplemental dolutegravir dosing, which is difficult to implement in high-burden settings. We aimed to test whether virological outcomes with standard-dose dolutegravir-based antiretroviral therapy (ART) are acceptable in people with HIV on rifampicin-based antituberculosis therapy. METHODS RADIANT-TB was a phase 2b, randomised, double-blind, non-comparative, placebo-controlled trial at a single site in Khayelitsha, Cape Town, South Africa. Participants were older than 18 years of age, with plasma HIV-1 RNA greater than 1000 copies per mL, CD4 count greater than 100 cells per μL, ART-naive or first-line ART interrupted, and on rifampicin-based antituberculosis therapy for less than 3 months. By use of permuted block (block size of 6) randomisation, participants were assigned (1:1) to receive either tenofovir disoproxil fumarate, lamivudine, and dolutegravir plus supplemental 50 mg dolutegravir 12 h later or tenofovir disoproxil fumarate, lamivudine, and dolutegravir plus matched placebo 12 h later. Participants received standard antituberculosis therapy (rifampicin, isoniazid, pyrazinamide, and ethambutol for the first 2 months followed by isoniazid and rifampicin for 4 months). The primary outcome was the proportion of participants with virological suppression (HIV-1 RNA <50 copies per mL) at week 24 analysed in the modified intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT03851588. FINDINGS Between Nov 28, 2019, and July 23, 2021, 108 participants (38 female, median age 35 years [IQR 31-40]) were randomly assigned to supplemental dolutegravir (n=53) or placebo (n=55). Median baseline CD4 count was 188 cells per μL (IQR 145-316) and median HIV-1 RNA was 5·2 log10 copies per mL (4·6-5·7). At week 24, 43 (83%, 95% CI 70-92) of 52 participants in the supplemental dolutegravir arm and 44 (83%, 95% CI 70-92) of 53 participants in the placebo arm had virological suppression. No treatment-emergent dolutegravir resistance mutations were detected up to week 48 in the 19 participants with study-defined virological failure. Grade 3 and 4 adverse events were similarly distributed between the study arms. The most frequent grade 3 and 4 adverse events were weight loss (4/108 [4%]), insomnia (3/108 [3%]), and pneumonia (3/108 [3%]). INTERPRETATION Our findings suggest that twice-daily dolutegravir might be unnecessary in people with HIV-associated tuberculosis. FUNDING Wellcome Trust.
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Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Ying Zhao
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa; Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Bryony Simmons
- LSE Health, London School of Economics and Political Science, London, UK
| | - Zaayid Omar
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Claire M Keene
- Médecins Sans Frontières, Cape Town, South Africa; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Andrew M Hill
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa; Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
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26
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van der Laan LE, Garcia-Prats AJ, Schaaf HS, Chirehwa M, Winckler JL, Mao J, Draper HR, Wiesner L, Norman J, McIlleron H, Donald PR, Hesseling AC, Denti P. Erratum for van der Laan et al., "Pharmacokinetics and Dose Optimization Strategies of Para-Aminosalicylic Acid in Children with Rifampicin-Resistant Tuberculosis". Antimicrob Agents Chemother 2023:e0072023. [PMID: 37338349 DOI: 10.1128/aac.00720-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Affiliation(s)
- Louvina E van der Laan
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anthony J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jana L Winckler
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jun Mao
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Heather R Draper
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Norman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Peter R Donald
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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27
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Araya S, Pfister T, Blum K, Clemann N, Faltermann S, Wiesner L, Hawkins W, van de Gevel I, Versyck K. Controlling cleaning agent residues in pharmaceutical manufacturing: A harmonized scientific strategy. Regul Toxicol Pharmacol 2023:105430. [PMID: 37308050 DOI: 10.1016/j.yrtph.2023.105430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/23/2023] [Accepted: 06/02/2023] [Indexed: 06/14/2023]
Abstract
This paper proposes a scientifically justified and harmonized strategy to control cleaning agent ingredients' (CAIs) residues in pharmaceutical manufacturing. Firstly, we demonstrate that worst-case cleaning validation calculations on CAI residuals with representative GMP standard cleaning limits (SCLs) are enough to control CAI residues of low concern to safe levels. Secondly, a new harmonized strategy for the toxicological assessment of CAI residuals is presented and validated. The results establish a framework applicable to cleaning agent mixtures based on hazard and exposure considerations. This framework is primarily based on the hierarchy of a single CAI's critical effect, where the lowest resulting limit may become the driver of the cleaning validation process. The six critical effect groups are: (1) CAIs of low concern based on safe exposure reasoning; (2) CAIs of low concern based on the mode of action reasoning; (3) CAIs with local concentration-dependent critical effects; (4) CAIs with dose-dependent systemic critical effects for which a route-specific PDE should be calculated; (5) poorly characterized CAIs with unknown critical effect for which a default value of 100 μg/day is proposed; (6) poorly characterized CAIs which should be avoided because of potential mutagenicity and/or potency.
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Affiliation(s)
| | - T Pfister
- F. Hoffmann-La Roche AG, Switzerland
| | - K Blum
- GlaxoSmithKline GmbH & Co. KG, Germany
| | - N Clemann
- F. Hoffmann-La Roche AG, Switzerland
| | | | | | - W Hawkins
- SafeBridge Europe Ltd., United Kingdom
| | - I van de Gevel
- Janssen Pharmaceutical Companies of Johnson & Johnson, Belgium
| | - K Versyck
- Janssen Pharmaceutical Companies of Johnson & Johnson, Belgium
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28
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Cindi Z, Kawuma AN, Maartens G, Bradford Y, Sokhela S, Chandiwana N, Venter WDF, Wasmann RE, Denti P, Wiesner L, Ritchie MD, Haas DW, Sinxadi P. Pharmacogenetics of tenofovir clearance among Southern Africans living with HIV. Pharmacogenet Genomics 2023; 33:79-87. [PMID: 37098852 PMCID: PMC10154044 DOI: 10.1097/fpc.0000000000000495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
BACKGROUND Tenofovir is a component of preferred combination antiretroviral therapy (ART) regimens in Africa. Few pharmacogenetic studies have been conducted on tenofovir exposure in Africa, where genetic diversity is greatest. OBJECTIVE We characterized the pharmacogenetics of plasma tenofovir clearance in Southern Africans receiving tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF). METHODS Adults randomized to TAF or TDF in dolutegravir-containing arms of the ADVANCE trial (NCT03122262) were studied. Linear regression models stratified by study arm examined associations with unexplained variability in tenofovir clearance. We investigated genetic associations with polymorphisms selected a priori followed by genome-wide associations. RESULTS A total of 268 participants (138 and 130 in the TAF and TDF arm, respectively) were evaluable for associations. Among polymorphisms previously associated with any drug-related phenotype, IFNL4 rs12979860 was associated with more rapid tenofovir clearance in both arms (TAF: P = 0.003; TDF: P = 0.003). Genome-wide, the lowest P values for tenofovir clearance in TAF and TDF arms were LINC01684 rs9305223 (P = 3.0 × 10-8) and intergenic rs142693425 (P = 1.4 × 10-8), respectively. CONCLUSION Among Southern Africans randomized to TAF or TDF in ADVANCE, unexplained variability in tenofovir clearance was associated with a polymorphism in IFNL4, an immune-response gene. It is unclear how this gene would affect tenofovir disposition.
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Affiliation(s)
- Zinhle Cindi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Aida N. Kawuma
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yuki Bradford
- Department of Genetics, University of Pennsylvania, Philadelphia, PA, USA
| | - Simiso Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nomathemba Chandiwana
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Roeland E. Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marylyn D. Ritchie
- Department of Genetics and Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David W. Haas
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Internal Medicine, Meharry Medical College, Nashville, Tennessee, USA
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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29
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Shenje JT, Raubenheimer P, Wiesner L, Ross I. A description of the elevation of pericardial cortisol: cortisone ratio in patients with tuberculous pericarditis. Front Endocrinol (Lausanne) 2023; 14:1127550. [PMID: 37305052 PMCID: PMC10248178 DOI: 10.3389/fendo.2023.1127550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/10/2023] [Indexed: 06/13/2023] Open
Abstract
Pulmonary tuberculosis is an inflammatory disease associated with an elevated cortisol/cortisone ratio at the site of infection and an array of cytokine changes. Tuberculous pericarditis is a less common but more lethal form of tuberculosis and has a similar inflammatory process in the pericardium. As the pericardium is largely inaccessible, the effect of tuberculous pericarditis on pericardial glucocorticoids is largely unknown. We wished to describe pericardial cortisolcortisone ratio in relation to plasma and saliva cortisol/cortisone ratios and the associated changes in cytokine concentrations. The median (interquartile range) of plasma, pericardial, and saliva cortisol concentration was 443 (379-532), 303 (257-384), and 20 (10-32) nmol/L, respectively, whereas the median (interquartile range) of plasma, pericardial, and saliva cortisone concentrations was 49 (35-57), 15.0 (0.0-21.7), and 37 (25-55) nmol/L, respectively. The cortisol/cortisone ratio was highest in pericardium with median (interquartile range) of 20 (13-445), followed by plasma of 9.1 (7.4-12.1) and saliva of 0.4 (0.3-0.8). The elevated cortisol/cortisone ratio was associated with elevated pericardial, interferon gamma, tumor necrosis factor-alpha, interleukin-6, interleukin-8, and induced protein 10. Administration of a single dose of 120 mg of prednisolone was associated with the suppression of pericardial cortisol and cortisone within 24 h of administration. The cortisol/cortisone ratio was highest at the site of infection, in this case, the pericardium. The elevated ratio was associated with a differential cytokine response. The observed pericardial cortisol suppression suggests that 120 mg of prednisolone was sufficient to evoke an immunomodulatory effect in the pericardium.
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30
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Watson DJ, Wiesner L, Matimela T, Beukes D, Meyers PR. Tandem LC-MS Identification of Antitubercular Compounds in Zones of Growth Inhibition Produced by South African Filamentous Actinobacteria. Molecules 2023; 28:molecules28114276. [PMID: 37298751 DOI: 10.3390/molecules28114276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/20/2023] [Accepted: 05/19/2023] [Indexed: 06/12/2023] Open
Abstract
Novel antitubercular compounds are urgently needed to combat drug-resistant Mycobacterium tuberculosis (Mtb). Filamentous actinobacteria have historically been an excellent source of antitubercular drugs. Despite this, drug discovery from these microorganisms has fallen out of favour due to the continual rediscovery of known compounds. To increase the chance of discovering novel antibiotics, biodiverse and rare strains should be prioritised. Subsequently, active samples need to be dereplicated as early as possible to focus efforts on truly novel compounds. In this study, 42 South African filamentous actinobacteria were screened for antimycobacterial activity using the agar overlay method against the Mtb indicator Mycolicibacterium aurum under six different nutrient growth conditions. Known compounds were subsequently identified through extraction and high-resolution mass spectrometric analysis of the zones of growth inhibition produced by active strains. This allowed the dereplication of 15 hits from six strains that were found to be producing puromycin, actinomycin D and valinomycin. The remaining active strains were grown in liquid cultures, extracted and submitted for screening against Mtb in vitro. Actinomadura napierensis B60T was the most active sample and was selected for bioassay-guided purification. This resulted in the identification of tetromadurin, a known compound, but which we show for the first time to have potent antitubercular activity, with the MIC90s within the range of 73.7-151.6 nM against M. tuberculosis H37RvTin vitro under different test conditions. This shows that South African actinobacteria are a good source of novel antitubercular compounds and warrant further screening. It is also revealed that active hits can be dereplicated by HPLC-MS/MS analysis of the zones of growth inhibition produced by the agar overlay technique.
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Affiliation(s)
- Daniel J Watson
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town 7700, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town 7700, South Africa
| | - Tlhalefo Matimela
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town 7700, South Africa
| | - Denzil Beukes
- School of Pharmacy, University of the Western Cape, Bellville 7535, South Africa
| | - Paul R Meyers
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town 7700, South Africa
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31
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Abdelgawad N, Wasserman S, Abdelwahab MT, Davis A, Stek C, Wiesner L, Black J, Meintjes G, Wilkinson RJ, Denti P. Linezolid population pharmacokinetic model in plasma and cerebrospinal fluid among patients with tuberculosis meningitis. medRxiv 2023:2023.04.06.23288230. [PMID: 37066148 PMCID: PMC10104225 DOI: 10.1101/2023.04.06.23288230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
Background Linezolid is being evaluated in novel treatment regimens for tuberculous meningitis (TBM). The pharmacokinetics of linezolid have not been characterized in this population, particularly in cerebrospinal fluid (CSF) where exposures may be affected by changes in protein concentration and rifampicin co-administration. Methods This was a sub-study of a phase 2 clinical trial of intensified antibiotic therapy for adults with HIV-associated TBM. Participants in the intervention groups received high-dose rifampicin (35 mg/kg) plus linezolid 1200 mg daily for 28 days followed by 600 mg daily until day 56. Plasma was intensively sampled, and lumbar CSF was collected at a single timepoint in a randomly allocated sampling window, within 3 days after enrolment. Sparse plasma and CSF samples were also obtained on day 28. Linezolid concentrations were analyzed using non-linear mixed effects modelling. Results 30 participants contributed 247 plasma and 28 CSF linezolid observations. Plasma PK was best described by a one-compartment model with first-order absorption and saturable elimination. The typical value of maximal clearance was 7.25 L/h. Duration of rifampicin co-treatment (compared on day 3 versus day 28) did not affect linezolid pharmacokinetics. Partitioning between plasma and CSF correlated with CSF total protein concentration up to 1.2 g/L where the partition coefficient reached a maximal value of 37%. The equilibration half-life between plasma and CSF was estimated at ∼3.5 hours. Conclusion Linezolid was readily detected in CSF despite co-administration of the potent inducer rifampicin at high doses. These findings support continued clinical evaluation of linezolid plus high-dose rifampicin for the treatment of TBM in adults.
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Kawuma AN, Wasmann RE, Sinxadi P, Sokhela SM, Chandiwana N, Venter WDF, Wiesner L, Maartens G, Denti P. Population pharmacokinetics of tenofovir given as either tenofovir disoproxil fumarate or tenofovir alafenamide in an African population. CPT Pharmacometrics Syst Pharmacol 2023. [PMID: 37013631 DOI: 10.1002/psp4.12955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 02/13/2023] [Accepted: 02/20/2023] [Indexed: 04/05/2023] Open
Abstract
Tenofovir disoproxil fumarate (TDF) and tenofovir alafenamide (TAF) are prodrugs of the nucleotide analogue tenofovir, which acts intracellularly to inhibit HIV replication. Whereas TDF converts to tenofovir in plasma and may cause kidney and bone toxicity, TAF mostly converts to tenofovir intracellularly, so it can be administered at lower doses. TAF leads to lower tenofovir plasma concentrations and lower toxicity, but there are limited data on its use in Africa. We used data from 41 South African adults living with HIV from the ADVANCE trial and described, with a joint model, the population pharmacokinetics of tenofovir given as TAF or TDF. The TDF was modeled to appear in plasma as tenofovir with a simple first-order process. Instead, two parallel pathways were used for a TAF dose: an estimated 32.4% quickly appeared as tenofovir into the systemic circulation with first-order absorption, whereas the rest was sequestered intracellularly and released into the systemic circulation as tenofovir slowly. Once in plasma (from either TAF or TDF), tenofovir disposition followed two-compartment kinetics and had a clearance of 44.7 L/h (40.2-49.5), for a typical 70-kg individual. This semimechanistic model describes the population pharmacokinetics of tenofovir when dosed as either TDF or TAF in an African population living with HIV and can be used as a tool for exposure prediction in patients, and to simulate alternative regimes to inform further clinical trials.
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Affiliation(s)
- Aida N Kawuma
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Roeland E Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Simiso M Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nomathemba Chandiwana
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Willem D F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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33
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Mazanhanga MT, Joubert A, Castel SA, van der Merwe M, Maartens G, Dooley KE, Upton CM, Wiesner L. Liquid chromatography-tandem mass spectrometry analysis of delamanid and its metabolite in human cerebrospinal fluid using protein precipitation and on-line solid-phase extraction. J Pharm Biomed Anal 2023; 227:115281. [PMID: 36739721 PMCID: PMC10023415 DOI: 10.1016/j.jpba.2023.115281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023]
Abstract
The penetration of the antituberculosis drug delamanid into the central nervous system is not established. The distribution of delamanid and its major metabolite, DM-6705, into the cerebrospinal fluid requires investigation. A liquid chromatography-tandem mass spectrometry method for the quantification of delamanid and DM-6705 in human cerebrospinal fluid was developed and validated. The calibration range for both analytes was 0.300 - 30.0 ng/mL. The deuterium-labelled analogue of delamanid (delamanid-d4) and OPC-14714 were used as internal standards for delamanid and DM-6705, respectively. Samples were processed by protein precipitation followed by on-line solid-phase extraction and high-performance liquid chromatography on an Agilent 1260 HPLC system. A Phenomenex Gemini-NX C18 (5.0 µm, 50 mm × 2.0 mm) analytical column was used for on-line solid-phase extraction, and a Waters Xterra MS C18 (5.0 µm, 100 mm × 2.1 mm) analytical column for chromatographic separation using gradient elution, at a flow rate of 300 µL/min. The total run time was 7.5 min. Analytes were detected by multiple reaction monitoring on an AB Sciex 5500 triple quadrupole mass spectrometer at unit mass resolution, with electrospray ionization in the positive mode. Accuracy and precision were assessed over three independent validation batches. Extraction recoveries were more than 98% and were consistent across the analytical range. Both analytes in CSF exhibited non-specific adsorption to polypropylene tubes. The method was used to analyse cerebrospinal fluid samples from patients with pulmonary tuberculosis in an exploratory pharmacokinetic study.
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Affiliation(s)
- Marian T Mazanhanga
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra A Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marthinus van der Merwe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
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34
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Chirehwa MT, Resendiz-Galvan JE, Court R, De Kock M, Wiesner L, de Vries N, Harding J, Gumbo T, Warren R, Maartens G, Denti P, McIlleron H. Optimizing Moxifloxacin Dose in MDR-TB Participants with or without Efavirenz Coadministration Using Population Pharmacokinetic Modeling. Antimicrob Agents Chemother 2023; 67:e0142622. [PMID: 36744891 PMCID: PMC10019313 DOI: 10.1128/aac.01426-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Moxifloxacin is included in some treatment regimens for drug-sensitive tuberculosis (TB) and multidrug-resistant TB (MDR-TB). Aiming to optimize dosing, we described moxifloxacin pharmacokinetic and MIC distribution in participants with MDR-TB. Participants enrolled at two TB hospitals in South Africa underwent intensive pharmacokinetic sampling approximately 1 to 6 weeks after treatment initiation. Plasma drug concentrations and clinical data were analyzed using nonlinear mixed-effects modeling with simulations to evaluate doses for different scenarios. We enrolled 131 participants (54 females), with median age of 35.7 (interquartile range, 28.5 to 43.5) years, median weight of 47 (42.0 to 54.0) kg, and median fat-free mass of 40.1 (32.3 to 44.7) kg; 79 were HIV positive, 29 of whom were on efavirenz-based antiretroviral therapy. Moxifloxacin pharmacokinetics were described with a 2-compartment model, transit absorption, and elimination via a liver compartment. We included allometry based on fat-free mass to estimate disposition parameters. We estimated an oral clearance for a typical patient to be 17.6 L/h. Participants treated with efavirenz had increased clearance, resulting in a 44% reduction in moxifloxacin exposure. Simulations predicted that, even at a median MIC of 0.25 (0.06 to 16) mg/L, the standard daily dose of 400 mg has a low probability of attaining the ratio of the area under the unbound concentration-time curve from 0 to 24 h to the MIC (fAUC0-24)/MIC target of >53, particularly in heavier participants. The high-dose WHO regimen (600 to 800 mg) yielded higher, more balanced exposures across the weight ranges, with better target attainment. When coadministered with efavirenz, moxifloxacin doses of up to 1,000 mg are needed to match these exposures. The safety of higher moxifloxacin doses in clinical settings should be confirmed.
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Affiliation(s)
- M. T. Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - J. E. Resendiz-Galvan
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - R. Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - M. De Kock
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SAMRC Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - L. Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - N. de Vries
- Brooklyn Chest Hospital, Cape Town, South Africa
| | - J. Harding
- DP Marais Hospital, Cape Town, South Africa
| | - T. Gumbo
- Quantitative Preclinical and Clinical Sciences Department, Praedicare Inc., Dallas, Texas, USA
| | - R. Warren
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SAMRC Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - G. Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - P. Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - H. McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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35
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Abdelgawad N, Tshavhungwe M(P, Rohlwink U, McIlleron H, Abdelwahab MT, Wiesner L, Castel S, Steele C, Enslin J(N, Thango NS, Denti P, Figaji A. Population Pharmacokinetic Analysis of Rifampicin in Plasma, Cerebrospinal Fluid, and Brain Extracellular Fluid in South African Children with Tuberculous Meningitis. Antimicrob Agents Chemother 2023; 67:e0147422. [PMID: 36815838 PMCID: PMC10019224 DOI: 10.1128/aac.01474-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/06/2023] [Indexed: 02/24/2023] Open
Abstract
Limited knowledge is available on the pharmacokinetics of rifampicin in children with tuberculous meningitis (TBM) and its penetration into brain tissue, which is the site of infection. In this analysis, we characterize the distribution of rifampicin in cerebrospinal fluid (CSF), lumbar (LCSF) and ventricular (VCSF), and brain extracellular fluid (ECF). Children with TBM were included in this pharmacokinetic analysis. Sparse plasma, LCSF, and VCSF samples were collected opportunistically, as clinically indicated. Brain ECF was sampled using microdialysis (MD). Rifampicin was quantified with liquid chromatography with tandem mass spectrometry in all samples, and 25-desacetyl rifampicin in the plasma samples. The data were interpreted with nonlinear mixed-effects modeling, with the CSF and brain ECF modeled as "effect compartments." Data were available from 61 children, with median (min-max) age of 2 (0.3 to 10) years and weight of 11.0 (4.8 to 49.0) kg. A one-compartment model for parent and metabolite with first-order absorption and elimination via saturable hepatic clearance described the data well. Allometric scaling, maturation, and auto-induction of clearance were included. The pseudopartition coefficient between plasma and LCSF/VCSF was ~5%, while the value for ECF was only ~0.5%, possibly reflecting low recovery of rifampicin using MD. The equilibration half-life between plasma and LCSF/VCSF was ~4 h and between plasma and ECF ~2 h. Our study confirms previous reports showing that rifampicin concentrations in the LCSF are lower than in plasma and provides novel knowledge about rifampicin in the VCSF and the brain tissue. Despite MD being semiquantitative because the relative recovery cannot be quantified, our study presents a proof-of-concept that rifampicin reaches the brain tissue and that MD is an attractive technique to study site-of-disease pharmacokinetics in TBM.
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Affiliation(s)
- Noha Abdelgawad
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Ursula Rohlwink
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Mahmoud T. Abdelwahab
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Chanel Steele
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Johannes (Nico) Enslin
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Nqobile Sindiswa Thango
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anthony Figaji
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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Okombo J, Kumar M, Redhi D, Wicht KJ, Wiesner L, Egan TJ, Chibale K. Pyrido-Dibemequine Metabolites Exhibit Improved Druglike Features, Inhibit Hemozoin Formation in Plasmodium falciparum, and Synergize with Clinical Antimalarials. ACS Infect Dis 2023; 9:653-667. [PMID: 36802523 DOI: 10.1021/acsinfecdis.2c00592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Structural modification of existing chemical scaffolds to afford new molecules able to circumvent drug resistance constitutes one of the rational approaches to antimalarial drug discovery. Previously synthesized compounds based on the 4-aminoquinoline core hybridized with a chemosensitizing dibenzylmethylamine side group showed in vivo efficacy in Plasmodium berghei-infected mice despite low microsomal metabolic stability, suggesting a contribution from their pharmacologically active metabolites. Here, we report on a series of these dibemequine (DBQ) metabolites with low resistance indices against chloroquine-resistant parasites and improved metabolic stability in liver microsomes. The metabolites also exhibit improved pharmacological properties including lower lipophilicity, cytotoxicity, and hERG channel inhibition. Using cellular heme fractionation experiments, we also demonstrate that these derivatives inhibit hemozoin formation by causing a buildup of toxic "free" heme in a similar manner to chloroquine. Finally, assessment of drug interactions also revealed synergy between these derivatives and several clinically relevant antimalarials, thus highlighting their potential interest for further development.
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Affiliation(s)
- John Okombo
- Department of Chemistry, University of Cape Town, Rondebosch, 7701 Cape Town, South Africa
| | - Malkeet Kumar
- Department of Chemistry, University of Cape Town, Rondebosch, 7701 Cape Town, South Africa
| | - Devasha Redhi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925 Cape Town, South Africa
| | - Kathryn J Wicht
- Department of Chemistry, University of Cape Town, Rondebosch, 7701 Cape Town, South Africa.,South African Medical Research Council Drug Discovery and Development Research Unit, Holistic Drug Discovery and Development (H3D) Centre, Rondebosch, 7701 Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Rondebosch, 7701 Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925 Cape Town, South Africa
| | - Timothy J Egan
- Department of Chemistry, University of Cape Town, Rondebosch, 7701 Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Rondebosch, 7701 Cape Town, South Africa
| | - Kelly Chibale
- Department of Chemistry, University of Cape Town, Rondebosch, 7701 Cape Town, South Africa.,South African Medical Research Council Drug Discovery and Development Research Unit, Holistic Drug Discovery and Development (H3D) Centre, Rondebosch, 7701 Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Rondebosch, 7701 Cape Town, South Africa
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37
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Zou Y, de Jager V, Hesseling AC, Diacon AH, Wiesner L, Mostert J, Svensson EM, Garcia-Prats A. Relative bioavailability of delamanid 50 mg tablets dispersed in water in healthy adult volunteers. Br J Clin Pharmacol 2023:10.1111/bcp.15672. [PMID: 36692865 PMCID: PMC10363574 DOI: 10.1111/bcp.15672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/25/2023] Open
Abstract
AIM Delamanid is a novel drug for the treatment of drug-resistant tuberculosis, manufactured as 50-mg solid and 25-mg dispersible tablets. We evaluated the effects of dispersing the 50-mg tablet, focusing on the relative bioavailability. METHODS Delamanid, 50-mg tablets administered dispersed vs swallowed whole, was investigated in a phase I, four-period, crossover study. Two of three dose strengths of delamanid (25, 50 or 100 mg) were given to healthy adult participants, in both whole and dispersed forms, with a 7-day washout period. Blood samples were collected over 168 h after each dose. Delamanid and its metabolite DM-6705 were analysed with a validated liquid chromatography tandem mass spectrometry assay. The pharmacokinetics of both analytes were analysed using nonlinear mixed-effect modelling. Palatability and acceptability were determined using a standardized questionnaire. RESULTS Twenty-four participants completed the study. The bioavailability of dispersed tablets was estimated to be 107% of whole tablets, with a 90% confidence interval of 99.7-114%, fulfilling bioequivalence criteria. The two formulations were not significantly different regarding either bioavailability or its variability. Bioavailability increased at lower doses, by 34% (26-42%) at 50 mg and by 74% (64-86%) at 25 mg, relative to 100 mg. The majority of participants (93%) found the dispersed formulation acceptable in palatability across all delamanid doses. CONCLUSIONS Dispersed 50-mg delamanid tablets have similar bioavailability to tablets swallowed whole in adult volunteers. This can be an option for children and other patients who cannot swallow whole tablets, improving access to treatment.
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Affiliation(s)
- Yuanxi Zou
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Veronique de Jager
- TASK Applied Science, TASK Clinical Research Centre, Cape Town, South Africa
| | - Anneke C. Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Andreas H. Diacon
- TASK Applied Science, TASK Clinical Research Centre, Cape Town, South Africa
| | - Lubbe Wiesner
- UCT Pharmacology Research Laboratory, Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Joni Mostert
- TASK Applied Science, TASK Clinical Research Centre, Cape Town, South Africa
| | - Elin M. Svensson
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anthony Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA
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38
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Ayton S, Schwitters A, Mantell JE, Nuwagaba-Biribonwoha H, Hakim A, Hoffman S, Biraro S, Philip N, Wiesner L, Gummerson E, Brown K, Nyogea D, Barradas D, Nzima M, Fischer-Walker C, Payne D, Mulenga L, Mgomella G, Kirungi WL, Maile L, Aibo D, Musuka G, Mugurungi O, Low A. Male partner age, viral load, and HIV infection in adolescent girls and young women: evidence from eight sub-Saharan African countries. AIDS 2023; 37:113-123. [PMID: 36129107 PMCID: PMC11000148 DOI: 10.1097/qad.0000000000003388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE We aimed to elucidate the role of partnerships with older men in the HIV epidemic among adolescent girls and young women (AGYW) aged 15-24 years in sub-Saharan Africa. DESIGN Analysis of Population-based HIV Impact Assessments in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe. METHODS We examined associations between reported partner age and recent HIV infection among AGYW, incorporating male population-level HIV characteristics by age-band. Recent HIV infection was defined using the LAg avidity assay algorithm. Viremia was defined as a viral load of more than 1000 copies/ml, regardless of serostatus. Logistic regression compared recent infection in AGYW with older male partners to those reporting younger partners. Dyadic analysis examined cohabitating male partner age, HIV status, and viremia to assess associations with AGYW infection. RESULTS Among 17 813 AGYW, increasing partner age was associated with higher odds of recent infection, peaking for partners aged 35-44 (adjusted odds ratio = 8.94, 95% confidence interval: 2.63-30.37) compared with partners aged 15-24. Population-level viremia was highest in this male age-band. Dyadic analyses of 5432 partnerships confirmed the association between partner age-band and prevalent HIV infection (male spousal age 35-44-adjusted odds ratio = 3.82, 95% confidence interval: 2.17-6.75). Most new infections were in AGYW with partners aged 25-34, as most AGYW had partners in this age-band. CONCLUSION These results provide evidence that men aged 25-34 drive most AGYW infections, but partners over 9 years older than AGYW in the 35-44 age-band confer greater risk. Population-level infectiousness and male age group should be incorporated into identifying high-risk typologies in AGYW.
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Affiliation(s)
- Sarah Ayton
- ICAP at Columbia University, New York
- Department of Epidemiology, Mailman School of Public Health, New York, New York, USA
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Mexico
| | - Amee Schwitters
- US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Joanne E. Mantell
- Department of Psychiatry, HIV Center for Clinical and Behavioral, Studies, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | | | - Avi Hakim
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Susie Hoffman
- Department of Epidemiology, Mailman School of Public Health, New York, New York, USA
- Department of Psychiatry, HIV Center for Clinical and Behavioral, Studies, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | | | | | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Kristin Brown
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | | | | | - Danielle Payne
- US Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Lloyd Mulenga
- Department of Infectious Diseases, Zambia Ministry of Health and University Teaching Hospital, Lusaka, Zambia
| | - George Mgomella
- US Centers for Disease Control and Prevention, Dar es Salaam, Tanzania
| | | | - Limpho Maile
- Family Health Division, Ministry of Health, Maseru, Lesotho
| | | | | | - Owen Mugurungi
- AIDS and TB Programme, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Andrea Low
- ICAP at Columbia University, New York
- Department of Epidemiology, Mailman School of Public Health, New York, New York, USA
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39
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Perumal R, Naidoo K, Naidoo A, Letsoalo MP, Esmail A, Joubert I, Denti P, Wiesner L, Padayatchi N, Maartens G, Dheda K. The impact of enteral feeding and therapeutic monitoring of rifampicin with dose escalation in critically ill patients with tuberculosis. Int J Infect Dis 2023; 126:174-180. [PMID: 36462574 DOI: 10.1016/j.ijid.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/14/2022] [Accepted: 11/27/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Critically ill patients with tuberculosis (TB) face a high mortality risk and require effective treatment. There is a paucity of data on rifampicin pharmacokinetics, the impact of continuous enteral feeding on drug absorption, and the potential of therapeutic drug monitoring (TDM) to optimize drug exposure in these patients. METHODS We performed a sequential pharmacokinetic study to determine the impact of feeding and TDM with rifampicin dose escalation in critically ill patients with TB. Noncompartmental pharmacokinetic analysis was performed. RESULTS Among 20 critically ill patients (40% were HIV-infected), median rifampicin Cmax (maximum serum concentration) in the fasted and fed states were 5.1 µg/ml versus 3.3 µg/ml, respectively (P <0.0001; geometric mean ratio 1.95; 90% confidence interval 1.46-2.60). The proportion of patients with low rifampicin concentrations in the fasted and fed states was 80% vs 100% (P-value = 0.1336). Optimized dosing led to a per-patient median rifampicin dosing of 24.6 mg/kg and a median Cmax increase from 2.4 µg/ml to 17.8 µg/ml (P-value = 0.0005; geometric mean ratio 8.29; 90% confidence interval 3.88-17.74). TDM-guided dose escalation increased the proportion of patients achieving the suggested target rifampicin concentration compared with standard dosing (83% vs 0%, P-value = 0.004). CONCLUSION We found low rifampicin concentrations in all patients receiving continuous enteral feeding. TDM-guided dose escalation provided an effective strategy to achieve target drug exposure in these critically ill patients with TB.
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Affiliation(s)
- Rubeshan Perumal
- Centre for Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa; Medical Research Council-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa; Medical Research Council-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Anushka Naidoo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Marothi P Letsoalo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Aliasgar Esmail
- Centre for Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Ivan Joubert
- Division of Critical Care Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, South Africa Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa; Medical Research Council-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Centre for Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine and University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; South African Medical Research Council Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Mondleki E, Banda CG, Chandiwana NC, Sokhela S, Wiesner L, Venter F, Maartens G, Sinxadi PZ. Effect of obesity on dolutegravir exposure in Black Southern African adults living with HIV. South Afr J HIV Med 2022; 23:1452. [PMID: 36751628 PMCID: PMC9772744 DOI: 10.4102/sajhivmed.v23i1.1452] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/31/2022] [Indexed: 12/23/2022] Open
Abstract
Background Dolutegravir, a component of the preferred first-line antiretroviral therapy regimen, has been associated with increased weight gain. South Africa has a high prevalence of obesity, especially among women. Understanding dolutegravir exposure in patients with obesity is important for dose optimisation. Objectives We compared the pharmacokinetic parameters of dolutegravir in Southern African adults living with HIV with and without obesity. Method Blood samples were collected at various time points over a 24 h-period for dolutegravir assays. Non-compartmental analysis was conducted and geometric mean ratios (GMRs), with 90% confidence intervals (CIs), were generated to compare dolutegravir pharmacokinetic parameters between the groups. Regression analyses to assess predictors of dolutegravir exposure were done. Results Forty participants were enrolled, 26 were women and 10 had obesity. Dolutegravir area under the concentration-time curve to 24-h and the maximum concentrations were not statistically significantly lower in participants with obesity: GMR 0.91 (90% CI: 0.71-1.16) and GMR 0.86 (90% CI: 0.68-1.07), respectively. In a multivariate linear regression analysis adjusting for age, gender, body mass index, creatinine clearance and randomisation arm (tenofovir alafenamide or tenofovir disoproxil fumarate), a unit increase in body mass index was associated with 1.2% lower dolutegravir area under the concentration-time curve to 24-h (P = 0.035). Conclusion Dolutegravir exposure was marginally lower in participants with obesity, but this is not clinically significant. Our findings suggest that there is no need to dose adjust dolutegravir in people with obesity.
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Affiliation(s)
- Enkosi Mondleki
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Clifford G. Banda
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Simiso Sokhela
- Ezintsha, University of the Witwatersrand, Johannesburg, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Francois Venter
- Ezintsha, University of the Witwatersrand, Johannesburg, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Phumla Z. Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Joubert A, Joubert A, van der Merwe M, Norman J, Castel S, Denti P, Sliwa K, Maartens G, Sinxadi P, Wiesner L. Validation of a quantitative multiplex LC-MS/MS assay of carvedilol, enalaprilat, and perindoprilat in dried blood spots from heart failure patients and its cross validation with a plasma assay. J Mass Spectrom Adv Clin Lab 2022; 27:7-17. [PMID: 36568714 PMCID: PMC9772843 DOI: 10.1016/j.jmsacl.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/08/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Adherence to medication is an important determinant of outcomes in chronic diseases like heart failure. Drug assays provide objective adherence biomarkers. Dried blood spots (DBS) are appealing samples for drug assays due to less demanding transportation and storage requirements. Objectives To analytically validate a LC-MS/MS method for the simultaneous quantification of carvedilol, enalaprilat, and perindoprilat in DBS and evaluate the feasibility of using the method as an adherence determining assay. To validate the assay further clinically by establishing correlation and agreement between plasma and DBS samples from a pharmacokinetic pilot study. Methods The method was validated over a concentration range of 1.00-200 ng/mL according to FDA guidelines. Adherence tracking ability of the assay was evaluated using a pharmacokinetic pilot study. Correlation and agreement were evaluated through Deming regression and Bland-Altman analysis, respectively. Results Accuracy, precision, selectivity, and sensitivity were proven with complete and reproducible extraction recovery at all concentrations tested. Stability of the analytes in the matrix and throughout sample processing was proven. The full range of concentrations of the pharmacokinetic pilot study could be quantified for enalaprilat, but not for carvedilol and perindoprilat. The difference between the observed and calculated plasma concentrations was less than 20 % of their mean for >67 % of samples for all analytes. Conclusions The assay is suitable as a screening tool for carvedilol and perindoprilat, while suitable as an adherence determining assay for enalaprilat. Equivalence between observed and predicted plasma concentrations proves DBS and plasma concentrations can be used interchangeably.
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Key Words
- ACE-I, Angiotensin-converting enzyme inhibitors
- ALQ, Above the Limit of Quantitation
- Adherence
- BD, Bidaily
- BMI, Body mass index
- CHF, Chronic Heart Failure
- CID, Collision-induced dissociation
- CV, Co-efficient of variation
- Carvedilol
- DBS, Dried Blood Spots
- Dried blood spots
- EMA, European Medicines Agency
- ESI, Electrospray ionization
- Enalaprilat
- HF, Heart Failure
- ISTD, Internal standard
- ITP, Initial testing procedure
- LC-MS/MS
- LC-MS/MS, Liquid Chromatography with tandem mass spectrometry
- LLOQ, lower limit of quantitation
- LOD, Limit of detection
- MRM, Multiple reaction monitoring
- NYHA FC, New York Heart Association Functional Classification
- OD, Once Daily
- Perindoprilat
- QC DIL, Quality control dilution
- QC LLOQ, Quality control lowest level of quantification
- QC, Quality Control
- QCH, Quality control high
- QCL, Quality control low
- QCM, Quality control medium
- S/N, signal-to-noise ratio
- SOP, Standard operating procedure
- ULOQ, upper limit of quantification
- VAMS, volumetric absorptive micro sampling
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Affiliation(s)
- Andre Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marthinus van der Merwe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Norman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,Division of Cardiology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa,Corresponding author.
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Joseph Davey D, Nyemba DC, Castillo‐Mancilla J, Wiesner L, Norman J, Mvududu R, Mashele N, Johnson LF, Bekker L, Gorbach P, Coates TJ, Myer L. Adherence challenges with daily oral pre-exposure prophylaxis during pregnancy and the postpartum period in South African women: a cohort study. J Int AIDS Soc 2022; 25:e26044. [PMID: 36480171 PMCID: PMC9731362 DOI: 10.1002/jia2.26044] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Daily oral pre-exposure prophylaxis (PrEP) can reduce HIV acquisition. However, prevention effectiveness requires daily adherence prior to and during periods of sexual activity. Little is known about pharmacologic measures of PrEP adherence during pregnancy and postpartum and the factors related to optimal adherence during periods of sexual activity in this population. METHODS Between August 2019 and October 2021, we enrolled pregnant women without HIV at their first antenatal care visit followed-up through 12 months postpartum. Eligible women ≥16 years old received HIV prevention counselling and were offered oral PrEP (TDF-FTC). We quantified tenofovir-diphosphate (TFV-DP) in dried blood spots in women who reported taking PrEP in the past 30 days (at quarterly follow-up visits). We used regression models with generalized estimating equations to evaluate correlates of TFV-DP (any vs. none, and ≥2 vs. <2 doses/week), adjusting for maternal age and pregnancy status. RESULTS AND DISCUSSION In 382 women who started PrEP in pregnancy, returned for follow-up and reported PrEP use in the past 30 days, the median age was 27 years (interquartile range [IQR] = 23-32), and the median time on PrEP was 168 days (IQR = 84-252 days). Half of the samples had quantifiable TFV-DP at any time point (52%), declining from 67% of pregnant women 3 months post-initiation to 31% of postpartum women by 12 months. Overall, 72% had concentrations corresponding to <2 doses/week; 25% ≥2 doses/week; 3% 7 doses/week. Concentrations were lower in postpartum versus pregnancy (age-adjusted odds ratio [aOR] = 0.44; 95% confidence interval [CI] = 0.35-0.54). The correlation of self-reported adherence and TFV-DP ranged from -0.07 in pregnancy to 0.25 in postpartum women. Variables associated with having quantifiable TFV-DP included partner living with HIV/unknown serostatus (aOR = 1.50; 95% CI = 1.01-2.22), and reported frequency of sexual activity in the past month (aOR sex >5/month vs. no sex or <5 times/month = 2.11; 95% CI = 1.58-2.82) adjusting for age and pregnancy versus postpartum status. TFV-DP concentrations declined over follow-up time (aOR for 6 vs. 3 months = 0.49; 95% CI = 0.36-0.67). CONCLUSIONS Objectively measured adherence to PrEP was low overall and did not correlate with self-reported use. There is an urgent need for objective adherence measures to support clinical decision-making as well as adherence support interventions as part of PrEP services for pregnant and postpartum women at risk of HIV.
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Affiliation(s)
- Dvora Joseph Davey
- Division of Infectious DiseasesGeffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- The Desmond Tutu Health FoundationUniversity of Cape TownCape TownSouth Africa
| | - Dorothy C. Nyemba
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Jose Castillo‐Mancilla
- Division of Infectious DiseasesSchool of MedicineUniversity of Colorado‐Anschutz Medical CampusAuroraColoradoUSA
| | - Lubbe Wiesner
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jennifer Norman
- Division of Clinical PharmacologyDepartment of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Rufaro Mvududu
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Nyiko Mashele
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and ResearchUniversity of Cape TownCape TownSouth Africa
| | - Linda‐Gail Bekker
- The Desmond Tutu Health FoundationUniversity of Cape TownCape TownSouth Africa
| | - Pamina Gorbach
- Division of Infectious DiseasesGeffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Thomas J. Coates
- Division of Infectious DiseasesGeffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
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Abdelgawad N, Chirehwa M, Schutz C, Barr D, Ward A, Janssen S, Burton R, Wilkinson RJ, Shey M, Wiesner L, McIlleron H, Maartens G, Meintjes G, Denti P. Pharmacokinetics of antitubercular drugs in patients hospitalized with HIV-associated tuberculosis: a population modeling analysis. Wellcome Open Res 2022; 7:72. [PMID: 37008250 PMCID: PMC10050909 DOI: 10.12688/wellcomeopenres.17660.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Early mortality among hospitalized HIV-associated tuberculosis (TB/HIV) patients is high despite treatment. The pharmacokinetics of rifampicin, isoniazid, and pyrazinamide were investigated in hospitalized TB/HIV patients and a cohort of outpatients with TB (with or without HIV) to determine whether drug exposures differed between groups. METHODS Standard first-line TB treatment was given daily as per national guidelines, which consisted of oral 4-drug fixed-dose combination tablets containing 150 mg rifampicin, 75 mg isoniazid, 400 mg pyrazinamide, and 275 mg ethambutol. Plasma samples were drawn on the 3rd day of treatment over eight hours post-dose. Rifampicin, isoniazid, and pyrazinamide in plasma were quantified and NONMEM ® was used to analyze the data. RESULTS Data from 60 hospitalized patients (11 of whom died within 12 weeks of starting treatment) and 48 outpatients were available. Median (range) weight and age were 56 (35 - 88) kg, and 37 (19 - 77) years, respectively. Bioavailability and clearance of the three drugs were similar between TB/HIV hospitalized and TB outpatients. However, rifampicin's absorption was slower in hospitalized patients than in outpatients; mean absorption time was 49.9% and 154% more in hospitalized survivors and hospitalized deaths, respectively, than in outpatients. Higher levels of conjugated bilirubin correlated with lower rifampicin clearance. Isoniazid's clearance estimates were 25.5 L/h for fast metabolizers and 9.76 L/h for slow metabolizers. Pyrazinamide's clearance was more variable among hospitalized patients. The variability in clearance among patients was 1.70 and 3.56 times more for hospitalized survivors and hospitalized deaths, respectively, than outpatients. Conclusion. We showed that the pharmacokinetics of first-line TB drugs are not substantially different between hospitalized TB/HIV patients and TB (with or without HIV) outpatients. Hospitalized patients do not seem to be underexposed compared to their outpatient counterparts, as well as hospitalized patients who survived vs who died within 12 weeks of hospitalization.
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Affiliation(s)
- Noha Abdelgawad
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - David Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, University of Liverpool, Liverpool, L3 5QA, UK
| | - Amy Ward
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Saskia Janssen
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, 19268, The Netherlands
| | - Rosie Burton
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Khayelitsha Hospital, Department of Medicine, Khayelitsha, 7784, South Africa
| | - Robert J. Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
- The Francis Crick Institute, London, NW1 1AT, UK
| | - Muki Shey
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, 7925, South Africa
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
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Zuma P, Joubert A, van der Merwe M, Norman J, Waitt C, Court R, Loveday M, Castel S, Wiesner L. Validation and application of a quantitative LC-MS/MS assay for the analysis of first-line anti-tuberculosis drugs, rifabutin and their metabolites in human breast milk. J Chromatogr B Analyt Technol Biomed Life Sci 2022; 1211:123489. [PMID: 36215877 PMCID: PMC9652742 DOI: 10.1016/j.jchromb.2022.123489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/21/2022] [Accepted: 09/29/2022] [Indexed: 11/19/2022]
Abstract
Breast milk is the preferred method of infant nutrition. Breastfeeding infants born to mothers treated for TB may be at risk of drug toxicity through breast milk exposure, or potentially be vulnerable to select for drug resistance with low level drug exposure. Except for isoniazid, the quantification of first-line TB drugs including rifabutin in breast milk has not been previously described and will provide much-needed insight to TB drug exposure in breastfeeding infants. We developed and validated a novel method to quantify several first-line TB drugs and their major metabolites in breast milk. Accuracy and precision were assessed during three consecutive, independent validation batches over a calibration range of 0.300-30.0 µg/mL for isoniazid and ethambutol, 0.150-15.0 µg/mL for acetyl isoniazid, desacetyl rifampicin, rifampicin, and pyrazinamide, 0.0150-1.50 µg/mL for rifabutin, and 0.00751-0.751 µg/mL for deacetyl rifabutin in breast milk. The method was reproducible for all analytes when using breast milk from six different sources and was not influenced by matrix effects with a mean regression precision (CV(%)) ranging between 1.0 and 2.8. The average recovery of analytes from the matrix was 76.7-99.1%, with a CV(%) between 0.4 and 4.4, while the average process efficiency was between 74.4 and 93.1% with a CV(%) between 1.9 and 8.3. Although only acetyl isoniazid, isoniazid, ethambutol, and pyrazinamide were successfully assayed in breast milk, samples taken from mothers treated for rifampicin-resistant TB and the inclusion of all first-line TB drugs, including rifabutin in the assay development and validation process will allow future quantification of these analytes in breast milk.
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Affiliation(s)
- Phiwe Zuma
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marthinus van der Merwe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jennifer Norman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Department of Pharmacology and Therapeutics, University of Liverpool, UK
| | - Richard Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marian Loveday
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, KwaZulu-Natal, South Africa; CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
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Béranger A, Bekker A, Solans BP, Cotton MF, Mirochnick M, Violari A, Wang J, Cababasay M, Wiesner L, Browning R, Moye J, Capparelli EV, Savic RM. Influence of NAT2 Genotype and Maturation on Isoniazid Exposure in Low-Birth-Weight and Preterm Infants With or Without Human Immunodeficiency Virus (HIV) Exposure. Clin Infect Dis 2022; 75:1037-1045. [PMID: 35134861 PMCID: PMC9522418 DOI: 10.1093/cid/ciac001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Isoniazid (INH) metabolism depends on the N-acetyl transferase 2 (NAT2) enzyme, whose maturation process remains unknown in low birth weight (LBW) and preterm infants. We aimed to assess INH exposure and safety in infants receiving oral tuberculosis prevention. METHODS This population pharmacokinetics (PK) analysis used INH and N-acetyl-isoniazid (ACL) concentrations in infants (BW ≤ 4 kg), including preterm, with follow-up for 6 months. PK parameters were described using nonlinear mixed effects modeling. Simulations were performed to assess INH exposure and optimal dosing regimens, using 2 targets: Cmax at 3-6 mg/L and area under the curve (AUC) ≥ 10.52 mg h/L. RESULTS We included 57 infants (79% preterm, 84% LBW) in the PK analysis, with a median (range) gestational age of 34 (28.7-39.4) weeks. At the time of sampling, postnatal age was 2.3 (0.2-7.3) months and weight (WT) was 3.7 (0.9-9.3) kg. NAT2 genotype was available in 43 (75.4%) patients (10 slow, 26 intermediate, and 7 fast metabolizers). Ninety percent of NAT2 maturation was attained by 4.4 post-natal months. WT, postmenstrual age, and NAT2 genotype significantly influenced INH exposure, with a 5-fold difference in AUC between slow and fast metabolizers for the same dose. INH appeared safe across the broad range of exposure for 61 infants included in the safety analysis. CONCLUSIONS In LBW/preterm infants, INH dosing needs frequent adjustment to account for growth and maturation. Pharmacogenetics-based dosing regimens is the most powerful approach to deliver safe and equalized exposures for all infants, because NAT2 genotype highly impacts INH pharmacokinetic variability.
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Affiliation(s)
- Agathe Béranger
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Adrie Bekker
- Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Belén P Solans
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Mark F Cotton
- Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Mark Mirochnick
- Division of Neonatology, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Jiajia Wang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Heath, Boston, Massachusetts, USA
| | - Mae Cababasay
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Heath, Boston, Massachusetts, USA
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Renee Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
| | - Jack Moye
- Division of Extramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Edmund V Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
- Pediatrics Department, Rady Children’s Hospital San Diego, University of California San Diego, La Jolla, California, USA
| | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, USA
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46
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Odayar J, Orrell C, Phillips TK, Hu NC, Kabanda S, Malaba TR, Allerton J, Wiesner L, Hsiao NY, Castillo-Mancilla J, Lesosky M, Myer L. Use of Tenofovir Diphosphate Levels to Predict Viremia During the Postpartum Period in Women Living With Human Immunodeficiency Virus (HIV): A Nested Case-Control Study. Clin Infect Dis 2022; 75:761-767. [PMID: 34979553 PMCID: PMC9477450 DOI: 10.1093/cid/ciab1068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There are few data on the utility of tenofovir diphosphate (TFV-DP) in dried blood spots (DBSs) to predict future viral load (VL) in postpartum women with HIV on antiretroviral therapy (ART). METHODS We conducted a nested case-control study within a trial of postpartum ART delivery strategies. Participants started ART containing tenofovir disoproxil fumarate (TDF) in pregnancy, were <10 weeks postpartum, and had a VL <400 copies/mL. VL and TFV-DP samples were taken every 3-6 months over 24 months. Cases had ≥1 VL ≥20 copies/mL; controls were randomly sampled from women with persistent viral suppression (VS; VL <20 copies/mL). Generalized estimating equations were used to calculate likelihood odds ratios (LORs) for future VL ≥20 copies/mL by TFV-DP concentration at the preceding visit. RESULTS 61 cases and 20 controls contributed 365 DBS-VL pairs (median ART duration, 16 months). Sensitivity and specificity of TFV-DP <700 fmol/punch to detect future viremia were 62.9% (95% CI, 54.7-70.6%) and 89.7% (84.9-93.4%), respectively. Adjusting for age, ART duration, previous VL, and duration between the TFV-DP and VL measures, LORs of viremia for TFV-DP concentrations 350-699 and <350 fmol/punch versus TFV-DP ≥1850 fmol/punch were 3.5 (95% CI, 1.1-10.8; P = .033) and 12.9 (3.6-46.6; P < .0001), respectively. Including only samples taken during VS, the LOR of future viremia for TFV-DP concentration <350 fmol/punch versus TFV-DP ≥1850 fmol/punch was 9.5 (1.9-47.0). CONCLUSIONS TFV-DP concentrations in DBSs were strongly associated with future viremia and appear useful to identify nonadherence and predict future elevated VL.
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Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Department of Medicine and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town Medical School, Cape Town, South Africa
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nai Chung Hu
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Siti Kabanda
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Thokozile R Malaba
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Joanna Allerton
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nei yuan Hsiao
- Division of Medical Virology, National Health Laboratory Service, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africaand
| | - Jose Castillo-Mancilla
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Maia Lesosky
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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47
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Beesham I, Mansoor LE, Joseph Davey DL, Palanee-Phillips T, Smit J, Ahmed K, Selepe P, Louw C, Singata-Madliki M, Kotze P, Heffron R, Parikh UM, Wiesner L, Rees H, Baeten JM, Beksinska M. Brief Report: Quantifiable Plasma Tenofovir Among South African Women Using Daily Oral Pre-exposure Prophylaxis During the ECHO Trial. J Acquir Immune Defic Syndr 2022; 91:26-30. [PMID: 35972853 PMCID: PMC9377486 DOI: 10.1097/qai.0000000000003023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND HIV endpoint-driven clinical trials provide oral pre-exposure prophylaxis (PrEP) as HIV prevention standard of care. We evaluated quantifiable plasma tenofovir among South African women who used oral PrEP during the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial. METHODS ECHO, a randomized trial conducted in 4 African countries between 2015 and 2018, assessed HIV incidence among HIV-uninfected women, aged 16-35 years, randomized to 1 of 3 contraceptives. Oral PrEP was offered onsite as part of the HIV prevention package at the South African trial sites. We measured tenofovir in plasma samples collected at the final trial visit among women reporting ongoing PrEP use. We used bivariate and multivariate logistical regression to assess demographic and sexual risk factors associated with plasma tenofovir quantification. RESULTS Of 260 women included, 52% were ≤24 years and 22% had Chlamydia trachomatis at enrollment. At PrEP initiation, 68% reported inconsistent/nonuse of condoms. The median duration of PrEP use was 90 days (IQR: 83-104). Tenofovir was quantified in 36% (n = 94) of samples. Women >24 years had twice the odds of having tenofovir quantified vs younger women (OR = 2.12; 95% confidence interval = 1.27 to 3.56). Women who reported inconsistent/nonuse of condoms had lower odds of tenofovir quantification (age-adjusted OR = 0.47; 95% confidence interval = 0.26 to 0.83). CONCLUSIONS Over a third of women initiating PrEP and reporting ongoing use at the final trial visit had evidence of recent drug exposure. Clinical trials may serve as an entry point for PrEP initiation among women at substantial risk for HIV infection with referral to local facilities for ongoing access at trial end. CLINICAL TRIAL NUMBER NCT02550067.
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Affiliation(s)
- Ivana Beesham
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Leila E. Mansoor
- Centre for AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Dvora L. Joseph Davey
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jenni Smit
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Khatija Ahmed
- Setshaba Research Centre, Soshanguve, South Africa
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | | | - Cheryl Louw
- Madibeng Centre for Research, Brits, South Africa
- Department of Family Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Mandisa Singata-Madliki
- Effective Care Research Unit, Universities of the Witwatersrand and Fort Hare and Eastern Cape Department of Health, East London, South Africa
| | - Philip Kotze
- Qhakaza Mbokodo Research Clinic, Ladysmith, South Africa;
| | - Renee Heffron
- Department of Global Health and Department of Epidemiology, University of Washington, Seattle, WA
| | - Urvi M. Parikh
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa;
| | - Helen Rees
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jared M. Baeten
- Department of Global Health, Department of Epidemiology, Department of Medicine, University of Washington, Seattle, WA; and
- Gilead Sciences, Foster City, CA
| | - Mags Beksinska
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
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48
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Gausi K, Chirehwa M, Ignatius EH, Court R, Sun X, Moran L, Hafner R, Wiesner L, Rosenkranz SL, de Jager V, de Vries N, Harding J, Gumbo T, Swindells S, Diacon A, Dooley KE, McIlleron H, Denti P. Pharmacokinetics of standard versus high-dose isoniazid for treatment of multidrug-resistant tuberculosis. J Antimicrob Chemother 2022; 77:2489-2499. [PMID: 35678468 PMCID: PMC10146925 DOI: 10.1093/jac/dkac188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 05/13/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The WHO-endorsed shorter-course regimen for MDR-TB includes high-dose isoniazid. The pharmacokinetics of high-dose isoniazid within MDR-TB regimens has not been well described. OBJECTIVES To characterize isoniazid pharmacokinetics at 5-15 mg/kg as monotherapy or as part of the MDR-TB treatment regimen. METHODS We used non-linear mixed-effects modelling to evaluate the combined data from INHindsight, a 7 day early bactericidal activity study with isoniazid monotherapy, and PODRtb, an observational study of patients on MDR-TB treatment including terizidone, pyrazinamide, moxifloxacin, kanamycin, ethionamide and/or isoniazid. RESULTS A total of 58 and 103 participants from the INHindsight and PODRtb studies, respectively, were included in the analysis. A two-compartment model with hepatic elimination best described the data. N-acetyltransferase 2 (NAT2) genotype caused multi-modal clearance, and saturable first-pass was observed beyond 10 mg/kg dosing. Saturable isoniazid kinetics predicted an increased exposure of approximately 50% beyond linearity at 20 mg/kg dosing. Participants treated with the MDR-TB regimen had a 65.6% lower AUC compared with participants on monotherapy. Ethionamide co-administration was associated with a 29% increase in isoniazid AUC. CONCLUSIONS Markedly lower isoniazid exposures were observed in participants on combination MDR-TB treatment compared with monotherapy. Isoniazid displays saturable kinetics at doses >10 mg/kg. The safety implications of these phenomena remain unclear.
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Affiliation(s)
- Kamunkhwala Gausi
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | | | - Richard Court
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Xin Sun
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Laura Moran
- Social & Scientific Systems, a DLH Company, Silver Spring, MD, USA
| | - Richard Hafner
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | - Tawanda Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Susan Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
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49
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Watson DJ, Laing L, Beteck RM, Gibhard L, Haynes RK, Wiesner L. The evaluation of ADME and pharmacokinetic properties of decoquinate derivatives for the treatment of malaria. Front Pharmacol 2022; 13:957690. [PMID: 36091789 PMCID: PMC9450014 DOI: 10.3389/fphar.2022.957690] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/18/2022] [Indexed: 12/03/2022] Open
Abstract
The emergence of Plasmodium falciparum (Pf) parasite strains tolerant of the artemisinin component and resistant to the other drug component in artemisinin combination therapies (ACTs) used for treatment now markedly complicates malaria control. Thus, development of new combination therapies are urgently required. For the non-artemisinin component, the quinolone ester decoquinate (DQ) that possesses potent activities against blood stage Pf and acts on a distinct target, namely the Pf cytochrome bc1 complex, was first considered. However, DQ has poor drug properties including high lipophilicity and exceedingly poor aqueous solubility (0.06 μg/ml), rendering it difficult to administer. Thus, DQ was chemically modified to provide the secondary amide derivative RMB005 and the quinoline O-carbamate derivatives RMB059 and RMB060. The last possesses sub-nanomolar activities against multidrug resistant blood stages of Pf, and P. berghei sporozoite liver stages. Here we present the results of ADME analyses in vitro and pharmacokinetic analyses using C57BL/6 mice. The amide RMB005 had a maximum mean whole blood concentration of 0.49 ± 0.02 µM following oral administration; however, the area under the curve (AUC), elimination half-life (t1/2) and bioavailability (BA) were not significantly better than those of DQ. Surprisingly, the quinoline O-carbamates which can be recrystallized without decomposition were rapidly converted into DQ in human plasma and blood samples. The maximum concentrations of DQ reached after oral administration of RMB059 and RMB060 were 0.23 ± 0.05 and 0.11 ± 0.01 µM, the DQ elimination half-lives were 4.79 ± 1.66 and 4.66 ± 1.16 h, and the DQ clearance were 19.40 ± 3.14 and 21.50 ± 3.38 respectively. Under these assay conditions, the BA of DQ could not be calculated Overall although RMB059 and -060 are labile in physiological medium with respect to the DQ parent, the potential to apply these as prodrugs is apparent from the current data coupled with their ease of preparation.
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Affiliation(s)
- Daniel J. Watson
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lizahn Laing
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Richard M. Beteck
- Centre of Excellence for Pharmaceutical Sciences, School of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Liezl Gibhard
- Department of Chemistry, University of Cape Town, Cape Town, South Africa
| | - Richard K. Haynes
- Centre of Excellence for Pharmaceutical Sciences, School of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- *Correspondence: Lubbe Wiesner,
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50
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Tanneau L, Karlsson MO, Diacon AH, Shenje J, De Los Rios J, Wiesner L, Upton CM, Dooley KE, Maartens G, Svensson EM. Population Pharmacokinetics of Delamanid and its Main Metabolite DM-6705 in Drug-Resistant Tuberculosis Patients Receiving Delamanid Alone or Coadministered with Bedaquiline. Clin Pharmacokinet 2022; 61:1177-1185. [PMID: 35668346 PMCID: PMC9349160 DOI: 10.1007/s40262-022-01133-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Delamanid is a nitroimidazole, a novel class of drug for treating tuberculosis, and is primarily metabolized by albumin into the metabolite DM-6705. The aims of this analysis were to develop a population pharmacokinetic (PK) model to characterize the concentration-time course of delamanid and DM-6705 in adults with drug-resistant tuberculosis and to explore a potential drug-drug interaction with bedaquiline when coadministered. METHODS Delamanid and DM-6705 concentrations after oral administration, from 52 participants (of whom 26 took bedaquiline concurrently and 20 were HIV-1 positive) enrolled in the DELIBERATE trial were analyzed using nonlinear mixed-effects modeling. RESULTS Delamanid PK were described by a one-compartment disposition model with transit compartment absorption (mean absorption time of 1.45 h [95% confidence interval 0.501-2.20]) and linear elimination, while the PK of DM-6705 metabolite were described by a one-compartment disposition model with delamanid clearance as input and linear elimination. Predicted terminal half-life values for delamanid and DM-6705 were 15.1 h and 7.8 days, respectively. The impact of plasma albumin concentrations on delamanid metabolism was not significant. Bedaquiline coadministration did not affect delamanid PK. Other than allometric scaling with body weight, no patients' demographics were significant (including HIV). CONCLUSIONS This is the first joint PK model of delamanid and its DM-6705 metabolite. As such, it can be utilized in future exposure-response or exposure-safety analyses. Importantly, albumin concentrations, bedaquiline coadministration, and HIV co-infection (dolutegravir coadministration) did not have an effect on delamanid and DM-6705 PK.
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Affiliation(s)
- Lénaïg Tanneau
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | | | | | - Justin Shenje
- SATVI, University of Cape Town, Cape Town, South Africa
| | - Jorge De Los Rios
- Barranco Clinical Research Site, Asociacion Civil Impacta Salud y Educacion, Lima, Peru
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Elin M Svensson
- Department of Pharmacy, Uppsala University, Uppsala, Sweden.
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
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